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C-1 Appendix C NASS Case Investigation Forms
C-2 Figure C.01 Scale: 1 centimeter=_______meters 02/07/02 10th Revision Figure C.01: Collision Diagram Form Page 1
C-3 Figure C.02 02/07/02 10th Revision Figure C.02: Collision Diagram Measurement Form Page 1
C-4 Figure C.03 Item Distance and Direction From Reference Point Distance and Direction From Reference Line 02/07/02 10th Revision Figure C.03: Collision Diagram Measurement Form Page 2
C-5 Figure C.04 02/07/02 10th Revision Figure C.04: General Vehicle Form Page 1
C-6 Figure C.05 02/07/02 10th Revision Figure C.05: General Vehicle Form Page 2
C-7 Figure C.06 02/07/02 10th Revision Figure C.06: General Vehicle Form Page 3
C-8 Figure C.07 02/07/02 10th Revision Figure C.07: General Vehicle Form Page 4
C-9 Figure C.08 02/07/02 10th Revision Figure C.08: General Vehicle Form Page 5
C-10 Figure C.09 02/07/02 10th Revision Figure C.09: General Vehicle Form Page 6
C-11 Figure C.10 02/07/02 10th Revision Figure C.10: General Vehicle Form Page 7
C-12 Figure C.11 02/07/02 10th Revision Figure C.11: General Vehicle Form Page 8
C-13 Figure C.12 02/07/02 10th Revision Figure C.12: Exterior Vehicle Form Page 1
C-14 Figure C.13 02/07/02 10th Revision Figure C.13: Exterior Vehicle Form Page 2
C-15 Figure C.14 Figure C.14: Exterior Vehicle Form Page 3
C-16 Figure C.15 Figure C.15: Exterior Vehicle Form Page 4
C-17 Figure C.16 Figure C.16: Exterior Vehicle Form Page 5
C-18 Figure C.17 04/01/02 12th Revision Figure C.17: Occupant Assessment Form Page 1
C-19 Figure C.18 04/01/02 12th Revision Figure C.18: Occupant Assessment Form Page 2
C-20 Figure C.19 04/01/02 12th Revision Figure C.19: Occupant Assessment Form Page 3
C-21 Figure C.20 04/01/02 12th Revision Figure C.20: Occupant Assessment Form Page 4
C-22 Figure C.21 04/01/02 12th Revision Figure C.21: Occupant Assessment Form Page 5
C-23 Figure C.22 04/01/02 12th Revision Figure C.22: Occupant Assessment Form Page 6
C-24 Figure C.23 1. Primary Sampling Unit Number _____ _____ 2. Case Number - Stratum _____ _____ _____ _____ 3. Vehicle Number _____ _____ 4. Occupant Number _____ _____ OCCUPANT INJURY DATA Record below the actual injuries sustained by this occupant that were identified from the official and unofficial data sources. Remember not to double count an injury just because it was identified from two different sources. If greater than ten injuries have been documented, encode the balance on the Occupant Injury Supplement. A.I.S. â 90 Source of Injury Data Body Region Type of Anatomic Structure Specific Anatomic Structure Level of Injury A.I.S. Severity Aspect Injury Source Injury Source Confidence Level Direct/ Indirect Injury Injury Intrusion Related 1- Yes 2-No 3-Unknown 1st 5.___ 6.___ 7.___ 8.__ __ 9.__ __ 10.___ 11.___ 12.__ __ __ 13.___ 14.___ 15.___ 2nd 16.___ 17.___ 18.___ 19.__ __ 20.__ __ 21.___ 22.___ 23.__ __ __ 24.___ 25.___ 26.___ 3rd 27.___ 28.___ 29.___ 30.__ __ 31.__ __ 32.___ 33.___ 34.__ __ __ 35.___ 36.___ 37.___ 4th 38.___ 39.___ 40.___ 41.__ __ 42.__ __ 43.___ 44.___ 45.__ __ __ 46.___ 47.___ 48.___ 5th 49.___ 50.___ 51.___ 52.__ __ 53.__ __ 54.___ 55.___ 56.__ __ __ 57.___ 58.___ 59.___ 6th 60.___ 61.___ 62.___ 63.__ __ 64.__ __ 65.___ 66.___ 67.__ __ __ 68.___ 69.___ 70.___ 7th 71.___ 72.___ 73.___ 74.__ __ 75.__ __ 76.___ 77.___ 78.__ __ __ 79.___ 80.___ 81.___ 8th 82.___ 83.___ 84.___ 85.__ __ 86.__ __ 87.___ 88.___ 89.__ __ __ 90.___ 91.___ 92.___ 9th 93.___ 94.___ 95.___ 96.__ __ 97.__ __ 98.___ 99.___ 100.__ __ _ 101.___ 102.__ 103.___ 10th 104.__ 105.__ 106.___ 107.__ __ 108.__ __ 109.___ 110.__ 111.__ __ _ 112.___ 113.__ 114.___ HS Form 433B (1/96) This report is authorized by P.L. 80-563, Title 1, Section 106, 108, and 112. While you are not required to respond, your cooperation is needed to make the results of this data collection effort comprehensive, accurate, and timely 04/02/02 12th Revision Figure C.23: Occupant Injury Forms Page 1
C-25 Figure C.24 OCCUPANT INJURY DATA A.I.S. - 90 Source of Injury Data Body Region Type of Anatomic Structure Specific Anatomic Structure Level of Injury A.I.S. Severity Aspect Injury Source Injury Source Confidence Level Direct/ Indirect Injury Injury Intrusion Related 1- Yes 2-No 3-Unknown 11th __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 12th __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 13th __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 14th __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 15th __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 16th __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 17th __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 18th __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 19th __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 20th __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 21st __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 22nd __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 23rd __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 24th __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 25th __ __ __ _ _ _ _ __ __ _ _ _ __ __ __ 04/02/02 12th Revision Figure C.24: Occupant Injury Forms Page 2
C-26 Figure C.25 U.S. Department of Transportation National Highway Traffic Safety Administration GENERAL CRASH FORM National Automotive Sampling System Crash Causation Special Stud 1. Primary Sampling Unit Number _____ _____ 2. Case Number - Stratum _____ _____ _____ _____ CRASH DESCRIPTION Describe the crash sequence in detail including events/driver actions which resulted in crash occurrence. 02/07/02 10th Revision Figure C.25: General Crash Event Form Page 1
C-27 Figure C.26 02/07/02 10th Revision Figure C.26: General Crash Event Form Page 2
C-28 Figure C.27 CODES FOR CLASS OF VEHICLE (00) Not a motor vehicle (01) Subcompact/mini (wheelbase < 254 cm) (02) Compact (wheelbase > 254 but< 265 cm) (03) Intermediate (wheelbase>265 but <278 cm) (04) Full size (wheelbase > 278 but< 291 cm) (05) Largest (wheelbase > 291 cm) (09) Unknown passenger car size (14) Compact utility vehicle (15) Large utility vehicle (< 4,536 kgs GVWR) (16) Utility station wagon (< 4,536 kgs GVWR) (19) Unknown utility type (20) Minivan (< 4,536 kgs GVWR) (21) Large van (< 4,536 kgs GVWR) (24) Van based school bus (<4,536 kgs GVWR) (28) Other van type (< 4,536 kgs GVWR) (29) Unknown van type (< 4,536 kgs GVWR) (30) Compact pickup truck (<4,536kgs GVWR) (31) Large pickup truck (< 4,536 kgs GVWR) (38) Other pickup truck (< 4,536 kgs GVWR) (39) Unknown pickup truck type (<4,536 kgs GVWR) (45) Other light truck (< 4,536 kgs GVWR) (48) Unknown light truck type (< 4,536 kgs GVWR) (49) Unknown light vehicle type (50) School bus (excludes van based) (58) Other bus (> 4,536 kgs GVWR) (59) Unknown bus type (60) Truck (> 4,536 kgs GVWR) (67) Tractor without trailer (68) Tractor-trailer(s) (78) Unknown medium/heavy truck type (79) Unknown light/medium/heavy truck type (80) Motored cycle (90) Other vehicle (99) Unknown CODES FOR GENERAL AREA OF DAMAGE (GAD) CDS APPLICABLE AND OTHER VEHICLES (0) (N) (F) Not a motor vehicle Noncollision Front (R) (L) (B) Right side Left side Back (T) (U) (9) Top Undercarriage Unknown TDC APPLICABLE VEHICLES (0) (N) (F) (R) Not a motor vehicle Noncollision Front Right side (L) (B) (D) Left side Back of unit with cargo area (rear of trailer or straight truck) Back (rear of tractor) (C) (V) (T) (U) (9) Rear of cab Front of cargo area Top Undercarriage Unknown CODES FOR VEHICLE NUMBER OR OBJECT CONTACTED
C-29 (01-30) - Vehicle Number Noncollision (31) Overturn - rollover (excludes end-over-end) (32) Rollover - end-over-end (33) Fire or explosion (34) Jackknife (35) Other intraunit damage (specify): ________________________________ (36) Noncollision injury (38) Other noncollision (specify): ________________________________ (39) Noncollision - details unknown Collision With Fixed Object (41) Tree (< 10 cm in diameter) (42) Tree (> 10 cm in diameter) (43) Shrubbery or bush (44) Embankment (45) Breakaway pole or post (any diameter) Nonbreakaway Pole or Post (50) Pole or post (< 10cm in diameter) (51) Pole or post (>10cm but < 30cm in diameter) (52) Pole or post (>30cm in diameter) (53) Pole or post (diameter unknown) (54) Concrete traffic barrier (55) Impact attenuator (56) Other traffic barrier (includes guardrail) (specify):___________________________ (57) Fence (58) Wall (59) Building (60) Ditch or culvert (61) Ground (62) Fire hydrant (63) Curb (64) Bridge (68) Other fixed object (specify): ________________________________ (69) Unknown fixed object Collision With Nonfixed Object (70) Passenger car, light truck, van, or other vehicle not in-transport (71) Medium/heavy truck or bus not in-transport (72) Pedestrian (73) Cyclist or cycle (74) Other nonmotorist or conveyance ________________________________ (75) Vehicle occupant (76) Animal (77) Train (78) Trailer, disconnected in-transport (79) Object fell from vehicle in-transport (88) Other nonfixed object (specify): ________________________________ (89) Unknown nonfixed object (98) Other event (specify): ________________________________ (99) Other event (specify): ________________________________ 02/07/02 10th Revision Figure C.27: General Crash Event Form Page 3
C-30 Figure C.28 U.S. Department of Transportation National Highway Traffic Safety Administration CRASH EVENT ACCESSMENT FORM National Automotive Sampling System Crash Causation Special Study 03/01/02 13th Revision Figure C.28: Crash Event Form Page 1
C-31 Figure C.29 03/01/02 13th Revision Figure C.29: Crash Event Form Page 2
C-32 Figure C.30 03/01/02 13th Revision Figure C.30: Crash Event Form Page 3
C-33 Figure C.31 03/01/02 13th Revision Figure C.31: Crash Event Form Page 4
C-34 Figure C.32 03/01/02 13th Revision Figure C.32: Crash Event Form Page 5
C-35 Figure C.33 03/01/02 13th Revision Figure C.33: Crash Event Form Page 6
C-36 Figure C.34 03/01/02 13th Revision Figure C.34: Crash Event Form Page 7
C-37 Figure C.35 03/01/02 13th Revision Figure C.35: Crash Event Form Page 8
C-38 Figure C.36 03/01/02 13th Revision Figure C.36: Crash Event Form Page 9
C-39 Figure C.37 03/01/02 13th Revision Figure C.37: Crash Event Form Page 10
C-40 Figure C.38 03/01/02 13th Revision Figure C.38: Crash Event Form Page 11
C-41 Figure C.39 03/01/02 13th Revision Figure C.39: Crash Event Form Page 12
C-42 Figure C.40 03/01/02 13th Revision Figure C.40: Crash Event Form Page 13
C-43 Figure C.41 03/01/02 13th Revision Figure C.41: Crash Event Form Page 14
