Free Motor vehicle fatal supplement report - Wisconsin

MOTOR VEHICLE FATAL SUPPLEMENT REPORT
Wisconsin Department of Transportation MV3480 12/2005 s.346.70 Wis. Stats.

1. Document Number (From MV4000)

ACCIDENT INFORMATION
2. Accident Date (Mo-Day-Yr) 3. No. of Travel Lanes 4. Time Ambulance NOTIFIED

7. Roadway Surface Type 1 Concrete 2 Blacktop (Bituminous) 3 Brick or Block 4 Slag, Gravel or Stone 5 Dirt 8 Other

8. Roadway Profile 1 Level 2 Grade 3 Hillcrest 4 Sag

12. Special Use 0 No Special Use 1 Taxi 2 Vehicle Used as School Bus 3 Vehicle Used as Other Bus 4 Military 5 Police 6 Ambulance 7 Fire Truck
16. NAME First

Unit 1 Unit 2 Unit 3

a.m. a.m. p.m. p.m. 10. Relation To Roadway 11. Trafficway Flow 9. Special Jurisdiction 1 On Roadway 1 Not Physically Divided 0 No Special Jurisdiction 2 Shoulder (Two Way Trafficway) 1 National Park Service 2 Divided Highway, Median Strip 3 Median 2 Military 4 Roadside (Without Traffic Barrier) 3 Indian Reservation 5 Outside Right of Way 3 Divided Highway, Median Strip 4 College/University Campus 6 Off Roadway (With Traffic Barrier) 5 Other Federal Properties Location Unknown 4 One Way Trafficway 7 In Parking Lane 8 Gore VEHICLE INFORMATION 14. Fire Y/N 15. Estimated Travel Speed 13. Emergency Use Y/N See s.340.01(3), Unit 1 346.03 Wis. Stats. Unit 1 Unit 1 Unit 2 Unit 3 Unit 2 Unit 3 Unit 2 Unit 3

a.m. p.m.

5. Time Ambulance Arrived at SCENE

6. Time Ambulance Arrived at HOSPITAL

SURVIVING DRIVER INFORMATION
MI Last

Unit 1
19. Alcohol Test Given Y/N 21. Alcohol Test Type - Circle One 1. Evidential Test - Circle One 1A. Breath; 1B. Blood; 1C. Urine 20. Alcohol Test Results-Circle One 2. Preliminary Breath Test (PBT) 1. Actual-Give Results Results 3. Behavioral 2. Test Refused 4. Passive Alcohol Sensor (PAS) 3. Results Unknown 5. Observed
NAME First MI Last

17. Ejected Y/N

18. Extricated Y/N

22. Drug Test Given Y/N 24. Drug Test Results - Circle One 1. No Drugs Reported 2. Drugs Reported - Specify 3. Tested, Results Unknown

23. Drug Test Type - Circle One Blood Urine

{

Unit 2
Alcohol Test Given Y/N Alcohol Test Results - Circle One 1. Actual-Give Results Results 2. Test Refused 3. Results Unknown
NAME First

Ejected Y/N

Extricated Y/N

Alcohol Test Type - Circle One 1. Evidential Test - Circle One 1A. Breath; 1B. Blood; 1C. Urine 2. Preliminary Breath Test (PBT) 3. Behavioral 4. Passive Alcohol Sensor (PAS) 5. Observed
MI Last

Drug Test Given Y/N Drug Test Results - Circle One 1. No Drugs Reported 2. Drugs Reported - Specify 3. Tested, Results Unknown

Drug Test Type - Circle One Blood Urine

{

Unit 3
Alcohol Test Given Y/N Alcohol Test Results - Circle One 1. Actual-Give Results Results 2. Test Refused 3. Results Unknown Alcohol Test Type - Circle One 1. Evidential Test - Circle One 1A. Breath; 1B. Blood; 1C. Urine 2. Preliminary Breath Test (PBT) 3. Behavioral 4. Passive Alcohol Sensor (PAS) 5. Observed
MI Last

Ejected Y/N

Extricated Y/N

Drug Test Given Y/N Drug Test Results - Circle One 1. No Drugs Reported 2. Drugs Reported - Specify 3. Tested, Results Unknown

Drug Test Type - Circle One Blood Urine

{

FATALITY INFORMATION
25. Name - First 26. Ejected Y/N 27. Extricated Y/N 28. Date of Death 29. Time of Death

1. 2. 3.
30. Officer Completing Report - Print Name 31. Officer ID No 32. Enforcement Agency Name 33. Report Date

a.m. p.m. a.m. p.m. a.m. p.m.

Fatal Supplement Report Instructions
In the event of a fatal motor vehicle accident, complete this form MV3480 and mail it to: Traffic Accident Section Wisconsin Department of Transportation P O Box 7919 Madison WI 53707-7919 This form is necessary to comply with the requirements of the National Fatal Accident Reporting System (FARS). 1. Document Number (From MV4000) - In the box located in the upper right corner of this form, enter the document number from the corresponding MV4000 accident report. No. of Travel Lanes - Enter ONE of the following: A. The total number of travel lanes on an undivided roadway. OR B. The total number of lanes in ONE direction on a divided highway. If fatalities all occur on-scene, code the arrival time at the hospital of the next most severely injured person. Relation to Roadway - Enter the number that indicates where the first harmful event occurred. Estimated Travel Speed - Enter the estimated travel speed for EACH vehicle involved in the accident. Make sure the speed indicated is the estimated speed prior to the accident and NOT the estimated impact speed. If travel speed was not estimated, enter "unknown."

3.

6.

10. 15.

18. & 27. Extricated - Enter "Y" for YES if extrication equipment or other force had to be used to remove the person from the vehicle. 21. Alcohol Test Type - Indicate the method used to determine if alcohol was consumed by the surviving driver. If more than one type of test was given, indicate the lowest numbered test for the test type.