Florida Traffic Crash Report Manual

STATE
Department
OF
of Highway
Neil
Tallahassee.
FLORIDA
Safety
Kirkman
Florida
and
Motor
Building
32399-0500
Vehicles
Information About the

Florida Traffic Crash Report Forms
The Florida Traffic Crash Report, HSMV-90003, is used by law enforcement officers to report traffic crashes to the
Department of Highway Safety and Motor Vehicles.
This form is more commonly referred to as the "rong form report.
Florida law (s.316.066, [3][a], F.S.) requires an officer who investigates a motor vehicle crash to complete and forward
a written report to the department if the crash involves death or personal injury , leaving the scene involving damage
to attended vehicles or property (s. 316.061, [1 ], F .S. ,), or driving while under the influence of alcoholic beverages,
chemical substances, or controlled substances or driving with an unlawful blood alcohol level (s. 316.193, F.S.).
The long form mayor may not be used to report motor vehicle crashes that require a wrecker to remove one or more
vehicles from the scene of the crash because of disabling damage.
The long form report will always be used with the Florida Traffic Crash Narrative I Diagram Report, HSMV-90005.
In
some cases, the long form report will be used with the Florida Traffic Crash Report Update I Continuation Report,
HSMV-90004.
This generally occurs if four or more vehicles or pedestrians {continuation report) are involved in the
same traffic crash or if the original long form needs to changed {update report) in some way by the officer who
investigated
the traffic crash
The Law Enforcement Short Form Report / Driver Report of Traffic Crash / Driver Exchange of Information,
HSMV-90006,
is used as a short form report by an officer to report other types of traffic crashes to the department, as
a driver report if the driver is required to file a written report to the department, or as a driver exchange of information
form. If form HSMV-90006 is used as a short form the officer who investigates the traffic crash is only required to fill
in the shaded areas. However, law enforcement agencies can require their officers to fill in additional short form
data fields or complete the report.
The Commercial Vehicle Supplement Crash Report, HSMV-90007. is obsolete and no longer in use. The appropriate
data fields on form HSMV-90007 have been transferred to the long form report.
The Florida Traffic Crash Reports display a list of values for certain data fields that pertain to vehicles, drivers,
pedestrians, passengers, and the scene of the traffic crash. The investigating officer is required to select and enter a
value in the appropriate data field. Some data fields are constructed to accept more than one value if warranted.
The
values needed to complete the vehicle or pedestrian sections on forms HSMV-90003 (long form) and HSMV-90004
(update/continuation),
and passenger information on form HSMV-9000S (narrative/diagram)
form at the bottom of page one.
are located on the long
The values needed to complete the events section of these forms are displayed
next to the data fields on the back of form HSMV-90003 and form HSMV-90004.
completed based on the information requested at the top of each category .
The remaining data fields are
FLORIDA
TRAFFIC
CRASH
REPORT
DO NOT WRITE IN THIS SPACE
LONG
FORM
MAIL
TO.DEPT.
OFHIGHWAY
SAFETY
& MOTOR
VEHICLES,
TRAFFIC
CRASH
RECORDS,
NEILKIRKMAN
BUILDING,
TALLAHASSEE,
FL32399-0537
C .IDATEO"CRASH
TIME
OFCRASH
.g I """'OTV , "'TV ""n"

~ I COUNTY
I CITYCODE
~
C"'
.-4
ATNODE
NO
or FEET
AT THE INTERSECTION OF
I.u
~
"MILE(SJ
I:!
'.
TIMEOFFICER
NOTIFIEO
DAM
SEW
.=
DDD
FROM
NODE
NO.
!
TIMEOFFICER
ARRIVED
PM
DAM
CITYORTOWN
of
NEXT
NODE
NO
(street, road or highway)
HSMVCRASHREPORT
NUMBER
PM
I NOOFLANES
INVEST.
AGENCY
REPORT
NUMBER
I~
FROM INTERSEciioN
{CheckifinCityorTown)
COUNTY
=~.I
ONSTREET.
ROAD
ORHIGHWAY
oF (;Ueet, road or highway)
nnnn
YEAR:l
s
e
r
"MAKE
"TYPE
USE'
VEH.liCENSE NUMBER I STATE I VEHICLE IDENTIFICATION NUMBER
TRAILER TYPE
,. , ."
i);j
"".AT'
VEHICLE
TRAVELliNG
N SEW
c;;-;jDLj
_.."",,1
?~sted SD~ed EST. VEHICLE DAMAGE
RANCE
COMPANY
(liABIliTYORPIP)
(J
o I ~ NAME
OFVEHICLE
OWNER
(Check
BoxIfSame
AsDriver)D
" ~
NAME OF OWNER ( Trailer or Towed Vehicie)
.18
Undercarriage
...19 Overturn
.' 20 Windshield
21 Trailer
...SHOWFIRSTPOINT
" ,'.. .OF VEHICLE
rIi
POliCY
NUMBER
I. Disabling
2 Functional
n
3 NoDamaoe
EST TRAILERDAMAGE 'DAMAGE L

ANDCIRCLE
DAMAGED
AREAISI
1.TowRotation
list
VEHICLE REMOVED BY:
CURRENT
ADDRESS
(Number
andStreet))
CITYANDSTATE
CURRENT ADDRESS (Number and Street)
CITY AND STATE
1Driver F
2.TowOwner's
Request4Other L
ZIPCODE
2
NAMEOFMOTORCARRIER
(CoIM1ercial
Vehic~Only)
~I
IC
.51
!nl NAMEOFDRIVER(Take FromDriverlicense\I PEDESTRIAN
~
&
-~,- c---,"~.,,~--c-
UMBER
CURRENT
ADDRESS
(NumberandStreet)
CURRENT
ADDRESS
(Number
andStreet\\
,
cc',
3 Urine
ALC/DRUGIPHYS.DEF.I~
RACE
ISEX
PHYSICAL DEFECTS
1 NoDefectsKnown
2 EyesightDefect
3 FatigueI Asleep
-4
HearingDefect
5 Illness
1A
2B
I
6 Seizure,Epilepsy,Blackout
4 Dl Chauffeur
2 Black
7 OtherPhysicalDefect;
5 E/Operator
3 Hispanic
INJURY SEVERITY
6 E/ Oper-Rest
4 Other
1 None
7 None
2 Possible
REQUIRED
3 Non-lncapacitating
ENDORSEMENTS 1 Male
4 Incapacitating
1 Yes
2 Femaie 5 Fatal(Within30 Days)
2 No
6 Non-Traffic
Fatality
3 N" End""ement
I
1
2
3
4
5
6
ALCOHOL I DRUG USE

NotDrinkingor UsingDrugs
Alcohol-UnderInfluence
Drugs-UnderInfluence
Alcohol& Drugs-UnderInfluence
HadBeenDrinking
PendingALC/DRUGTest
Results
LOCATION
IN VEHICLE
1
2
3
4
5
6
7
8
9
I SAFETY EQUIPMENT IN USE

1 Notin use
2 SeatBelt I ShoulderHarness
3 ChildReslraint
4 Air Bag -Deployed
5 Air Bag -Not Deployed
6 SafetyHelmet
7 EyeProtection
I,
Page
HSMV.90003 (REV. 01/02)
INJ. ~O~
,
D
01 PrivateTranspol1ation
02 Commercial
Passengers
03 Commercial
Cargo
04 PubiicTransportation
05 PublicSchoolBus
06 PrivateSchoolBus
07 Ambuiance
08 law Enforcement
o9 FireI Rescue
10 Military
11 OtherGovernment
12 Dump
13 ConcreteMixer
14 Garbageor Refuse
15 CargoVan
77 r.hA.
DATEOFBIRTH
--
NUMBER FROM DIAMOND OR BOX

OM
OF DIAMOND
01 Automobile
02 Van
03 lightTrucklPU-2or 4 reartires
.-04
MediumTruck-4 reartires
'ro 05 HeavyTruck-2ormorerearaxle.
E 06 TruckTractor(Cab-Bobtail)
...07 MotorHome(RV)
~ 08 Bus( driver+ seatsfor 9-15)
-= 09 Bus( driver+ seatsfor over15)"
1 -..10
Bicycie
~
11 Motorcycle
O 12 Moped
U
13 AJITerrainVehicle
14 Train
15 low SpeedVehicle
77 r.h",
5 None
2 Breath 4 Refused
ERI1I.
BEING TRANSPORTED
us DOTnrICCMCInFNTIFIC'.ATION
NlIMRFRS
CITY STATE&2IP CODE
ALC/DRUGTESTTYPE
r1 Blood
1V..2No
Clrt, STATEANDZIPCOOE
-1-
Of -
Front Left
Front Center
Front Right
Rear Left
Rear Center
RearRight
In Body Of Truck
Bus Passenger
Other
1 No
2 Yes
p~~;~
jgj!!!.:!:1
Page
-2--
Of
Time
and Location Information

(Form NumberHSMV-90003)
DA TE OF CRASH
1DATE
~CRASH
II
1011101021
Enter the date of the traffic
crash
in month,
> Display
the month
> Display
the day by using the numbers
> Display
the appropriate
day, and year order in the following
by using the numbers
01 through
01 through
manner:
12.
31.
year as required.
TIME OF CRASH
I 11MEOF
CRA~
110:10
D PM I
~AM
Enter the time of day or the approximate

> Place an X or a check
* Midnight
is considered
NOTE:
time of day the traffic crash occurred.
mark in the AM or PM box

AM and noontime
Use the 12 hour clock system
is considered
to identify
PM.
the time of the crash.
Do not use the 24 hour clock system
(aka
military time)
TIME OFFICER
NOTIFIED
ITIMEOFFIC~OTI~
110:15
~AM
D PM 1
Enter the time of day you were notified

*
Midnight
NOTE:
is considered
TIME OFFICER
AM and noontime
system
NOTE:
(aka military
the time you were notified
of the traffic
crash.
Do not use the 24
time).

Midnight
to identify
PM.
D PM1
Enter the time of day you arrived
is considered
ARRIVED
1TIMEOFFIC~RRI~
~AM
mark in the AM or PM box.

hour clock
110:25
of the traffic crash.
is considered
at the scene of the traffic crash.

AM and noontime
is considered
to identify
use the 24 hour clock system
(aka military
PM.
the time you arrived

time).
04
at the scene
of the
traffic
crash.
Do not
Time and Location Information

(FormNumberHSMV-90003)
INVESTIGATING
AGENCY
REPORT
NUMBER
INVEST.
AGENCY
REPORT
NUMBER
01-011234567-01
This space
is used to identify
the investigating
> Enter the report or file number

> Enter the same investigating
law enforcement
assigned
agency
agency's
report or file number.
by the agency.
report or file number
on the Florida
Traffic
Crash
Report,
Narrative/Diagram,
HSMV-90005.
> Enter the same
investigating
Update/Continuation
HSMV
CRASH
I HSMV~~H
Report,
REPORT
REP~T ~UM~ER~
>
Enter
on the Florida
Traffic
Crash
Report,
HSMV-90004.
I
I
space
appears
report or file number
NUMBER
112345678
This
agency
is used
to
each
Florida
on
the
identify
the
Traffic
eight
digit
Crash
pre-printed
Report,
Long
same
pre-printed
crash
report
number
same
pre-printed
crash
report
number
crash
report
number.
Form,
HSMV-90003.
on
Florida
the
Traffic
pre-printed
Crash
Report,
crash
report
number
Narrative/Diagram,
HSMV-90005.
>
Enter
COUNTY
the
I CITY
I COU~ ~ C':v_C?DE
I
13/51
on
the
Update/Continuation
Report
(HSMV-90004).
CODE
I
I
This
space
is used
the
correct
codes.
>
Enter
the county
>
Enter
00 for the
to identify
and
city
city
the
code
code
county
and
city
(aka
place)
codes.
Please
refer
to appendix
1 for
as required.
if the traffic
crash
occurred
outside
the
corporate
limits
of the
city
or in an unincorporated
area
CITY OR TOWN
D t1 O Dol
Tall~~:;~0;~
(CheckilinCilyOlTown)
00
Example A
~
U
CITY
OR
TOWN
Tallahassee
(CheckilinCityOlTown)
D
Example B
s fe !'wr
!XJ O of
This space is used to identify the city or town where the traffic crash occurred or the nearest city or town to the
traffic crash scene.
Time

CITY OR TOWN (Continued)

> Enter the complete name of the city or town where the traffic crash occurred if it happened within the legal
boundaries
of a city or town (Example A), and place an X in the box titled "Check if in City or Town."
> If the traffic crash occurred outside the legal boundaries of a city or town, enter the distance in feet or miles to the
nearest city or town, the complete name of the nearest city or town, and place an X in the box that best describes
the direction of travel from the nearest city or town (Example 8).
COUNTY
II CO~~on
1,
This space
is used to identify
> Enter the complete
the county
name
crash.
FROM
NOOE
NO.
This space
FROM
NOOE
NO.
00001
is used to identify
Node numbers
location.
municipal
traffic
relative
are assigned
engineers
(county
> Enter the node number(s)

a node number
next closest
> If a traffic
closest
that
occurred
to the crash
node number
located
NUMBER
I NO.
OF~ES
I
4
Example
reference
for counting
in support
provided.
display
location
where
location.
side of the crash scene,
the frequency
of an active traffic
in the "At
in the vicinity
of traffic crashes
(state
roads)
at the same
and county
and
location
system.
ata
location
(intersection,bridge,etc.
(Example
has not been assigned,
node number
space
enter the node number

in feet or miles from
on the same
and enter it in the space titled "Next
and enter the
A).
Node No.", and enter the distance
the next closest
of the traffic
crash
Node Number"
Node No." space
a node number
Identify
numbers)
of Transportation
the number
in the space titled "From
to the crash
location
If a traffic crash occurred
on the same road in the "Next

at a location
on the opposite
Department
and city roads)
has been assigned
Example
(crash
by the Florida
in the spaces
node number
crash
node numbers
are used as a point of reference
The numbers
where
the traffic crash occurred.
of the county.
NODE NUMBERS
ATNODE
NO.
or
00000
ATNOOE
NO.
where
roadway
Node No."
that is
(Example
B).
OF LANES
I
I
This space
is used to identify
the number
of clearly
> Enter the total number
of lanes on the street,
turn lanes or safety
zones.).
If impact
roads.or
place the number
highways,
occurred
marked
lanes on the roadway(
road or highway
where
at an intersection
of lanes of the street,
s) of a street,
the traffic
between
road or highway
crash
vehicles
road or highway.
occurred.
travelling
with the highest
(Do not include

on different
streets,
class of trafficway
in
Time
NUMBER
OF LANES
the space
Traffic
(Continued)
provided.
Crash

The highest
Report.
class of trafficway
Form Number
can be determined
HSMV-90003,
under the category
by referring
"Road
to page 2 of the Florida
System
Identifier."
DIVIDED-UNDIVIDED
n
W
I.DMDED I
2~~~I\/1n"n !
This space
Florida
Statutes,
roadways
impede
>
is used to identify
identifies
a divided
by an intervening
vehicular
Enter
the
ON STREET,
traffic.
street,
road or highway
space or by a physical
OR HIGHWA
barrier
as divided
as "any highway
or clearly
or undivided.
Section
that has been divided
indicated
dividing
section
where
the traffic
crash
316.090,(1),
into two or more
so constructed
as to
Street)
is used to identify
the name of the street,
> Enter the name of the street,
road or highway
Refer to page 2 of the Florida

System
is classified
..."
ONSTREET.
ROAD
ORHIGHWAY
U.S.90 (SR 9 or Tennessee
This space
road or highway
or 2 in the space provided
number
ROAD
if a street,
Identifier"
Traffic
to determine
Crash
road or highway
in the space
Report,
the class of trafficway.
provided.
Form Number
List the highest

HSMV-90003,
List the next highest
occurred.
class of trafficway
under the category
classification,
first
"Road
local names
or alias in
parentheses.
> If the traffic crash occurred in a parking lot, enter the name of the parking lot.
> If the traffic crash occurred on private property, enter "private property" and the address.
AT
THE
INTERSECTION
OF
ATTHEINTERSECTION
OF(street,
roadorhighway)
U.S.319
FROM
INTERSECTION
N
or
Example
OF
SEW
DDDD
FROM
INTERSECTION
OF(street,
roadorhighway)
U.S. 319
Example
This space is used to identify if the traffic crash occurred within the boundaries of an intersection or close to an
intersection.
An intersection crash is any traffic crash where the first harmful event occurs within the limits of the
intersection.
A general description of an intersection is "the lateral boundary lines of the roadways of two highways
which join one another at, or approximately at, right angles. .." (s. 316.003 [17], [a], Florida Statutes).
;1
AT
THE
INTERSECTION
OF (Continued)
> If the traffic crash occurred within an intersection, enter the name of the street, road or highway that intersects
with the previously identified street, road or highway (Example A).
> If the traffic crash occurred outside the boundaries of an intersection, enter the name of the nearest street, road or
highway, the distance in feet or miles, and the direction from the nearest street, road or highway (Example B).
List the highest class of trafficway.
Refer to page 2 of the Florida Traffic Crash Report, Form Number
HSMV-90003, under the category "Road System Identifier" to determine the class of trafficway.
Vehicle
or Pedestrian
Sections
(Form Number HSMV-90003)

Sections l' 2, and 3 are designed to identify vehicle, owner, driver, and pedestrian information. The following
instructions for entering data also apply to the vehicle or pedestrian sections on the Florida Traffic Crash Report,
Update / Continuation, HSMV-90004, when it is used as a continuation report to identify more than 3 vehicles or
pedestrians involved in the same traffic crash.
THE MARGIN
This space is used to identify vehicle or pedestrian involvement.

> Place an x or check mark in the vehicle or pedestrian box. Only one box per section can be marked.
DRIVER ACTION
This space is used to identify a phantom or hit-and -run driver. A phantom driver is a driver of a non-contact vehicle
who leaves the scene of a traffic crash. A hit-and-run driver is a driver who strikes another vehicle, pedestrian or
causes damage to other property and leaves the scene of a traffic crash.
> Enter the number 1 in the space provided if the driver is a phantom driver.
> Enter the number 2 in the space provided if the driver is a hit-and-run driver.
> Enter
the
number
3 in the
space
provided
if 1 or 2 does
not appiy
VEHICLE YEAR
c;:]
This space is used to display the vehicle year (manufacturer's
model year) of any vehicle involved in a traffic crash.
> Enter the vehicle year in the space provided.

> Enter UK in the space provided if the vehicle year is unknown.
> If not applicable, draw a diagonal line in the space provided.
VEHICLE
I
I
_.MAKE
Chev
This space
MAKE
I
I
is used to identify
the vehicle
manufacturer's
trade name
(Chevrolet,
Ford, Dodge)
of any vehicle
involved
in a traffic crash.
> Enter the first four letters or the complete name of the vehicle make. This information should be extracted
from the Florida Vehicle Registration Certificate or a similar out of state document.
for example, Impala, Crown Victoria or F-150.
> Enter UK in the space provided if the vehicle make is unknown.
> If not ~pplicable, draw a diagonal line in the space provided.
Do not use the model name;
Vehicle
or Pedestrian
Sections
VEHICLE
TYPE
~
~
This space
located
is used to identify
at the bottom
Information"
of page one on the Florida
type code in the space
> Enter UK in the space

> If not applicable,
provided
Traffic
in a traffic crash.
Crash
Report,
The vehicle
Long Form,
type codes
HSMV-90003,
are
in the "Code
vehicle
for general
work site) must be identified

02, commercial
for example,
commercial
or for a fee) must be identified
namely,
01, private
use (courier
by the vehicle
delivery
provided.
(private
use code;
cargo or 15 cargo van.

UPS or similar
type is unknown.
line in the space
to carry passengers
corresponding
that are operated
provided.
if the vehicle
draw a diagonal
Vans that are designed
vehicle
involved
section.
> Enter the vehicle
the proper
the type of vehicle
service)
transportation
A vehicle
that resembles
van, must be coded
or 02 commercial
or for transporting
type code 02 and the proper
by the vehicle
cargo
corresponding
a van in construction
type code 02 and

passengers.
(work van carrying

vehicle
use code;
but has 6 tires
as a truck based on the gross vehicle
weight
Vans
tools to
namely,
on the ground;
rating of the
in question.
Trucks are classified by the gross vehicle weight rating of the unit involved in the traffic crash. There are three
categories of trucks based on gross vehicle weight rating: light trucks, vehicle type code 03 (single unit under 10,000
pounds), includes pick up trucks with 4 rear tires; medium trucks, vehicle type code 04 (single unit 10,000 to 26,000
pounds); and heavy trucks vehicle type code 05 (single unit over 26,000 pounds).
have a separate vehicle code (06) that must be used for identification purposes.
rating appears on a label or tag affixed to single -unit trucks and truck tractors
Truck tractors (cab-bobtail)

The gross vehicle weight
manufactured for use in the
United States. The label is placed on the door or door frame next to the driver's seat.
Buses
have been divided
passengers
whose
the bus was designed
top speed
be operated
is greater
on streets
have a valid driver's

corresponding
into two separate
vehicle
types
to legally transport.
(codes
conditions,
08 and 09) based
A low speed
then 20 miles per hour but not greater
under certain
license.
vehicle
must be licensed
A golf cart is not considered
vehicle
15) is any 4 wheel
of
electric
than 25 miles per hour.
A low speed
for use on the highway,
and its operator
a low speed
use code.
(code
on the total number
vehicle.
All vehicle
types
must
vehicle
vehicle
must
have
can
Vehicle
or Pedestrian
Sections
VEHICLE
USE
M
~
This space
is used to identify
Florida Traffic
Crash
> Enter the vehicle
Report
being used.
(public
profit; for example,
Greyhound
(concrete
use codes
Information"
on page one of the
section.
provided.
use agree
in terms
of what the vehicle
is designed
type 01) is being used as a taxi, then the correct
school
bus).
transportation
students
to school,
If the same type of bus is owned

to citizens
Gorp., then the correct

to transport
are located
use is unknown.
If the same type of bus is owned
type 05) is designed
in the "Code
type 09) is being used to transport
of providing
transportation).
(vehicle
(vehicle
The vehicle
provided.
line in the space
bus) or 06 (private
entity for the purpose
HSMV-90003)
type and vehicle
If a bus (vehicle
characteristics.
if the vehicle
draw a diagonal
If an automobile
school
Number
provided
that the vehicle
passengers).
05 (public
(Form
vehicle
use code in the space
It is important
additional
and deliver
-even
cement
by or leased
for the purpose
use is 02 (commercial
use is 02 (commercial
then the correct
for a fee -, then the correct
by a company
vehicle
vehicle
to do or how it is
use is
to a government
vehicle
of transporting
passengers).
to a work site, then the correct
vehicle
vehicle
use is 04
passengers
for
If a heavy truck
use is 13
mixer).
VEHICLE
LICENSE
NUMBER
I VEH liCENSE NUMBER I

I
ABC-123
This
space
is
used
>
Enter
the
vehicle
>
Enter
UK
in
>
If. not
applicable,
the
to
identify
the
license
space
draw
vehicle
plate
number
provided
license
if
diagonal
of
plate
the
number
vehicle
of
involved
the
in
vehicle
the
space
supplying
power.
provided.
unknown.
line
in
the
space
provided.
STATE
~
~
This space
is used to identify
the state that issued
> Enter the state of issuance.
Use the standard,
the vehicle
license
plate
two letter postal service abbreviations for all states (Appendix 2).
> Enter UK in the space provided if unknown.

P.
venlcre
or pedestrian
~ectlons
VEHICLE
IDENTIFICATION
VEHICLE
IDENTIFICATION
NUMBER
NUMBER
01352PF64ATOOOO
This
space
is
used
to
>
Enter
the
complete
>
Enter
UK
in
>
If
not
jdentify
the
vehicle
the
space
applicable,
provided
draw
format.
vehicle.
identification
identification
if
diagonal
The vin is a set of numbers

coded
vehicle
number
generated
The vin also appears
of
(vin)
in
the
the
vehicle
space
supplying
power.
provided.
unknown.
line
The vin is recorded
number
in
the
space
provided.
by the vehicle
manufacturer
on a metal plate located
on the vehicle
registration
tnat aescrlDe
at the bottom
certificate
tne cnaracterlstlcs
of the windshield
issued
or a venlcle
on the driver's
by the state that licensed
In a
side of the
the vehicle
for
use
FIRST
POINT
~
OF
VEHICLE
DAMAGE
.In
ercamage
19 Overturn
.20 Windshield
11. 121Trailer
SHOWFIRSTPOINT
10 .OF VEHICLEn
DAMAGE ~
ANDCIRCLE
DAMAGED
AREA(S)
This space
is used to identify
the first point Of venlCle aamage
traffic crash. The first point of vehicle

> Enter the first point of vehicle
diagram.
TRAILER
for traffic
improperly
parked),
appear
VEHICLE
is used to identify
completed
Special
damage
Note:
crashes
in a separate
all trailers
involving
vehicle
which
damage
GENERAL
trailers
areas SUSIalnea oy a venlc;le III (1
that first strikes

by selecting
and all other damaged
another
vehicle
the corresponding
or object.
number
from the
areas on the diagram.
IIUN
vehicles
involved
that are being towed,
in traffic crashes.
trailers
This information
that are unhitched
(properly
must be
parked
or
towed venlcles
is being towed
or pedestrian
(box) provided
INt-UKMA
or towed
and all other driverless
Any vehicle
is that part of the vehicle
in the space
Circle the first point of vehicle
OR TOWED
This record
damage
ana OIner aamagea
and guided
section.
Dy a driver
posltlonea
oenlna
lne sleerlng
wneel
musl
Vehicle
or Pedestrian
Sections
TRAILER
OR
TOWED
VEHICLE
YEAR
rv"EARl
~
This
space
is used
to
of the
> Enter
the
year
> Enter
UK
in the
> if not
MAKE
or
model
year
towed
vehicle.
provided
draw
OR TOWED
the
trailer
space
applicable,
TRAILER
identify
of the
trailer
or
towed
vehicle
if unknown
a diagonal
line
VEHICLE
in the
space
provided.
MAKE
I Gatorl
This space
is used to identify
the vehicle
manufacturer's
trade name of a trailer
or towed
vehicle.
> Enter the first four letters or the complete name of the trailer or towed vehicle.
This information should be
extracted from the Florida Vehicle Registration Certificate or a similar out of state document.
TRAILER
OR
provided
if the vehicle
draw a diagonal
TOWED
VEHICLE
make is unknown.
line in the space
provided.
TYPE
I TRAILER TYPE I
I
01
This
space
located
is
on
used
page
to
one
identify
of
the
the
type
Florida
of
Traffic
trailer
or
Crash
towed
vehicle
Report
(Form
involved
Number
in
the
traffic
crash.
HSMV-90003)
in
The
the
"Code
trailer
type
codes
are
Information"
section.
> Enter the trailer type code (09 for towed vehicle)
If tandem
trailers
on the Florida
if the vehicle
draw a diagonal
(trailer
Traffic
06) also include
provided
enclosed
09) apply to other driverless
Report,
vehicles
provided.
in a traffic crash then the second
Update/Continuation
rental trailers,
provided
make is unknown.
line in the space
type 02) are involved
Crash
in the space
horse trailers,
being towed
(Form
Number
and trailers
by a wrecker
10
set of trailer
HSMV-90004).
used by lawn services.
or another
vehicle.
information
Utility trailers
Towed
must appear
(trailer
vehicle
type
(trailer
type
Vehicle
or Pedestrian
Sections
VEHICLE
LICENSE
NUMBER
-TRAILER
OR
TOWED
vehicle
license
plate
VEHICLE
I VEH. LICENSE NUMBER I

IpO9YB
This
space
is
used
>
Enter
the
vehicle
>
Enter
UK
in
>
If
not
STATE
the
to
identify
license
space
applicable,
plate
number
provided
draw
-TRAILER
the
if
diagonal
OR TOWED
in
the
number
space
of
the
trailer
or
towed
vehicle.
provided.
unknown.
line
in
the
space
provided.
VEHICLE
~
~
This space
is used to identify
the state that issued
> Enter the state of issuance.

VEHICLE
Use the standard,
provided
license
plate to the trailer
two letter postal service
abbreviations
or towed vehicle.
for all states
(Appendix
2).
if unknown.
draw a diagonal
IDENTIFICATION
the vehicle
line in the space
NUMBER
-TRAILER
provided.
OR TOWED
VEHICLE
VEHICLE
IDENTIFICATION
NUMBER
0642367UIL
This space
is used to identify
> Enter the complete
the vehicle
vehicle
identification
identification
provided
number
number
assigned
(vin) in the space
to the trailer
or towed
vehicle.
provided.
if unknown.
The vin is a set of numbers

coded
format.
registration
generated
The vin is recorded

certificate
issued
by the vehicle
on the forward
manufacturer
that describe
half of the left side of trailers.
by the state that licensed
the vehicle
11
for use.
the characteristics
of a vehicle
The vin also appears
in a
on the vehicle
Vehicle
or Pedestrian
Sections
VEHICLE
TRAVELING
ON
US 90 (Tennessee
This space
traveling
is used to identify
and name of the street,
occurred.
This space
road or highway
of travel on the street,
> Enter the estimated
speed
POSTED
55
the direction
> Enter the name of the street,
EstMPH
St.)
on when the traffic crash
> Enter the direction
AT
provided
is also used to identify
each vehicle
or pedestrian
road or highway
of the vehicle
involved
road or high\IVay the vehicle
prior to impact
or pedestrian
the estimated
was traveling
by placing
speed
was
of the vehicle.
on in the space
provided
an X in the correct
box.
in the traffic crash.
if unknown.
draw a diagonal
line in the space
provided.
SPEED
IPosted speedl
I 55
I
This
on
space
is used
to
at the
time
> Enter
the
posted
> Enter
UK
in the
> If not
the
1$
4000.00
space
is
estimates
of
crash
space
speed
for
the
street,
road
or
highway
the
vehicle
or
pedestrian
was
traveling
occurred.
in the
space
provided.
if unknown.
a diagonal
line
in the
space
provided.
DAMAGE
to
damage
posted
provided
draw
used
the
speed
VEHICLE
IEST. VEHICLE DAMAGE
This
traffic
applicable,
ESTIMATED
identify
identify
the
must
be
estimated
displayed
property
damaged
numerically
and
sustained
rounded
off
by
to
the
vehicle
nearest
>
Enter
the
estimated
amount
of
damage
in
the
space
provided
if
the
vehicle
involved
>
Enter
the
estimated
amount
of
damage
in
the
space
provided
if
the
vehicle
was
involved
in
traffic
crash.
All
dollar.
was
totaled.
damaged.
Do
not
enter
the
word
totaled.
> Enter 00 in the space provided if the vehicle was not damaged.
NOTE:
If a vehicle
a moving
security
owner
or driver
traffic citation,
is found to be uninsured
the Bureau
equal to the estimated
of Financial
amount
of vehicle
at the time of the traffic
Responsibility
damage.
12
may require
crash
and if the driver was issued
the owner
or driver
to post
Vehicle
or Pedestrian
Sections

DAMAGED SEVERITY
1.Disab.'ing
2. Fun~nal
3 NoDamage 1
This space
severity
is used to identify
to what extent
a vehicle
is damaged
There
are three categories
for assessing
damage
to a vehicle:
1. Disabling
Damage
is drivable
include
-vehicle
but must be towed
a drivable
2. Functional
operating
vehicle
Damage
from the scene of the traffic crash to prevent
because
additional
it is inoperable
damage.
or vehicle
This does not
that is towed from the scene of the traffic crash for any other reason.
-vehicle
is operable
and is driven
away from
the scene
of the traffic
crash
in its usual
manner.
3. No Damage
-no
visible
> Enter the appropriate

NOTE:
must be towed from the scene of the traffic crash
damage
severity
draw a diagonal
A traffic crash
Traffic
signs of damage.
involving
Crash
Report,
code in the space
line in the space
only disabling
Long Form,
provided.
provided.
damage
may be reported
HSMV-90003
to the Department
or the Law Enforcement
on the Florida
Short Form,
HSMV-90006
(s.316.066[3][a]3).
ESTIMATED
TRAILER
I EST. TRAILER DAMAGE
1$
1000.00
This
space
traffic
is
crash.
used
All
OR
to
TOWED
identify
the
estimates
of
VEHICLE
DAMAGE
estimated
damage
property
must
be
~,j
damaged
displayed
sustained
numerically
by
and
trailer
rounded
or
off
towed
to
the
vehicle
nearest
involved
in
dollar.
amount
of damage
in the space
provided
if the trailer or towed
vehicle
was damaged.
amount
of damage
in the space
provided
if the trailer or towed
vehicle
was totaled.
Do not
enter the word totaled.

> Enter 00 in the space
MOTOR
VEHICLE
provided
if the trailer or towed vehicle
draw a diagonal
INSURANCE
line in the space
COMPANY
(Liability
MOTOR
VEHICLE
INSURANCE
COMPANY
(liABIliTY
ORPIP)
Equate
Fire and Casualty
This
space
The
best
policy,
is used
source
an insurance
Insurance
to identify
for obtaining
binder
the
this
was not damaged.
provided.
or PIP)
POliCY
NUMBER
Company
motor
,~
vehicle
information
or a certificate
PBO9876
fnsurance
is a valid
of self
company
motor
insurance
vehicle
issued
Vehicles.
1-1
and
policy
insurance
by the
number
of
identification
Department
the
vehicle
card,
of Highway
owner
or driver.
an Insurance
Safety
and
Motor
Vehicle
or Pedestrian
Sections
> Enter the name of the motor vehicle insurance company in the space provided. .
> Enter the policy number, self insurance certificate number or the word binder in the space provided
> Enter UK in the space provided if unknown
> If not applicable, draw a diagonal line in the space provided
VEHICLE
REMOVED
BY
VEHICLE
REMOVED
BY;
Bob's
This
1 TowRotation
List
Garage
space
scene
is used
of the traffic
3.Driver n
2.TowOwner's
Request
4.Other ~
to identify
the
crash
how
and
name
of the
the vehicle
person,
was
garage,
or wrecker
service
that
removed
the vehicle
from
the
removed.
> Enter the name of the person, garage, or wrecker service in the space provided.
> Enter l' 2, 3, or 4 in the box provided to indicate how the vehicle was removed from the scene of the traffic crash.
> Enter UK in the space provided if unknown..
NAME
OF VEHICLE
OWNER
NAME
OFVEHICLE
OWNER
(Check
BoxIfSane
AsDriver)
O
Jimmy D. Doe
This space
is used to identify
> Enter the first name,
the owner
middle
of the vehicle
involved
in the traffic crash.
initial, and last name of the person
who owns the vehicle.
> Enter only one name if joint ownership is established.

> Enter "same as driver" if the owner and driver are the same and place an "X" in the box provided.
> Enter the full legal name of any company or corporation that owns the vehicle.
> Enter UK in the space provided if unknown..
VEHICLE
OWNER
CURRENT
ADDRESS
CURRENT
ADDRESS
(Number
andStreet))
Apt.
This
the
10, 1515 Angle
Street
space
to identify
traffic
is used
CITY
ANDSTATE
Triangle,
the
current
physical
ZIPCODE
FL
address
32000
or mailing
address.of
-000
the
owner
of the
vehicle
involved
in
crash
> Enter the street address
or mailing
address,
city, state and
zip code of the person
or mailing
address,
city, state and zip code of the company
vehicle.
> Do not abbreviate the name of the city.

> Use the standard two letter postal service abbreviations for all states (Appendix 2).
14

or corporation
that owns the
VEHICLE
OWNER
CURRENT

NAME
OF OWNER
ADDRESS
provided
if unknown.
draw a diagonal
(Trailer
(continued)
line in the space
or Towed
provided
Vehicle)
NAME
OFOWNER
(Trailer
orTowed
Vehicle)
Area Trucking Inc.
This space
is used to identify
the owner
middle
of the trailer or towed vehicle.
initial, and last name of the person
> Enter only one name if joint ownership
provided
or towed
vehicle
is established.
> Enter the full legal name of any company

who owns the trailer
or corporation
that owns the trailer
or towed
vehicle.
if unknown..
draw a diagonal
line in the space
provided.
TRAILER OR TOWED VEHICLE OWNER CURRENT ADDRESS

CURRENT
ADDRESS
(Number
and
-s"ireeij)
CITY AND STATE
1010 Radius Road

This space
Trianale.
is used to identify
the current
physical
ZIP CODE
FL
32303-0000
address
or mailing
address.of
the owner
of the trailer
or towed
vehicle.
> Enter the street
address
or mailing
address,
city, state and
zip code of the person
> Enter the street
address
or mailing
address,
city, state and zip code of the company
or corporation
that owns the
vehicle.
> Do not abbreviate
> Use the standard
NAME
OF MOTOR
the name of the city.

two letter postal service
CARRIER
(Commercial
abbreviations
Vehicle
for all states
(Appendix
3)
Only)
NAME
OFMOTOR
CARRIER
(Convnercial
Vehicle
Only)
Intermodallnc.
This space
partnership,
Shipping Go.
is used to identify
corporation,
the name of the motor carrier.
or religious
organization
A motor carrier
responsible
is "the business
for the transportation
of goods,
entity,
individual,
property,
or
people."
> Enter the name of the motor carrier.
name.
If the motor carrier

If the motor carrier
is a company
provided
draw a diagonal
or corporation
is a person
enter the full legal name,
if unknown..
line in the space
enter the first name,
provided.
15
middle
initial, and last
Vehicle
or Pedestrian
Sections
NAME OF MOTOR CARRIER (Commercial
Vehicle Only) -Continued
This space must be completed for any self-propelled vehicle -with
or without
a trailer -being
used in commerce to
transport cargo, or passengers, or any vehicle displaying a hazardous material placard including: a van (vehicle type
code 02); a light truck, with six tires on the ground (vehicle type code 03); a medium truck (vehicle type code 04); a
heavy truck (vehicle type code
05); a truck-tractor (vehicle type code 06); a bus designed to transport
9 to 15
passengers (vehicle type code 08); and a bus designed to transport over 15 passengers (vehicle type code 09).
The shipping
carrier.
papers
that drivers
carry in the cab of a truck are the best source
The name on the side of a truck can be different
of the cargo or passengers.
Example:
It is not unusual
than the person
or company
and semi-trailer
to display
for a tractor
John Smith owns a truck-tractor (bobtail).
for identifying
responsible
different
He contracts with White Manufacturing
its trailers loaded with its goods from New York to Los Angeles.
the name of the motor

for the movement
company
names.
Company to take one of
John Smith is the motor carrier because
his is the entity that has agreed to carry this particular load.
Example: John Smith, driving his truck-tractor, utilizes a cargo broker to obtain goods from Intermodallncorporated
Shipping Company for his return trip to New York. On the return trip, John Smith is again the carrier.
Example:
John Smith, driving his truck-tra~tor, leases his services to Polyester Chemical Company.
Polyester has
a contract to transport chemicals for a company based in St. Louis and directs Smith to deliver a
semi-trailer from New York to St. Louis. In this case, Polyester is the motor carrier, because it told
Smith to take the particular load.
Example:
John Smith is driving a tractor/semi-trailer.
The tractor and semi-trailer are owned by ABC Trucking, so
ABC Trucking is the motor carrier.

Example:
John Smith is driving a tractor owned by ABC Trucking which has been leased to XYZ Trucking Company.
XYZ used the tractor to pull XYZ trailers in its regular shipping service.
In this case XYZ is the motor
carrier because XYZ is directing the carrying of the load.

MOTOR
CARRIER
CURRENT
ADDRESS
CURRENT
ADDRESS
(Number
andStreet)
5060 Tango Street

This space
is used to identify
CITY
.STATE
AND
ZIPCODE
Triangle, FL 32000-0000
the current
or mailing
physical
address,
address
or mailing
city, state and
address.of
the owner
zip code of the motor carrier.

> Use the standard two letter postal service abbreviations for all states (Appendix 2).
1t:
of the motor carrier.
Vehicle
or Pedestrian
Sections
US
DOT or ICC IDENTIFICA
TION NUMBERS
This space is used to identify the United States Department of Transportation
(U S DOT) or the Interstate Commerce
Commission Motor Carrier (ICC MC) identification number assigned to the motor carrier.
> Enter the the US DOT identification number, if applicable, in the space provided.
six or seven digits,
NOTE: The digits are entered right-justified.
The US DOT number will have
Use zero(s) to fill any remaining boxes at the left
of the series
> Enter ICC MC identification number, if applicable, in the space provided. The ICC MC number
digits. In some cases, a motor carrier could have two or more ICC MC numbers.
one to record. NOTE: The digits are entered right-justified.
the
may have up to six
Officers should choose only
Use zero(s) to fill any remaining boxes at the left of
series.

> If not applicable, draw a diagonal line in the space provided
AU S DOT or an ICC MC identification number is issued to private fleet and for-hire vehicles involved in interstate
commerce.
The US DOT identification number is found only on vehicles of interstate
operating in the furtherance of any commercial enterprise).
private carriers (those trucks
The identification number is always preceded by the
abbreviation US DOT. The ICC MC identification number is found only on vehicles of interstate
(those in the transportation
business).
for-hire carriers
The identification number is usually preceded by the abbreviation ICC MC. In
some cases it may be preceded by just ICC or MC.
Vehicles which haul exempt commodities are not required to have
aU S DOT or an ICC MC number even if they travel across state lines. A motor carrier may have more than one
ICC MC number. Officers should choose only on~to record.
State numbers are issued by a state agency to vehicles that operate either in interstate commerce or only within that
state. Do not record the state number.
NAME OF DRIVER OR PEDESTRIAN

NAME
OFDRIVER
(Take
From
Driver
LiCense)
I PEDESTRIAN
Bonnie R. Doe
This space
crash.
is used to identify
A driver
exercising
is I! any person
control
of a vehicle

used to display
driver
license
the name of the driver of the vehicle
or steering
middle
the.name
is different
who drives
or is in actual
a vehicle
physical
control
being towed
driver on the Florida
or if a driver does not have a driver
17
of a vehicle
by a motor vehiclel!
initial, and last name of the driver
of a licensed
or the name of the pedestrian
or pedestrian
Driver
License.
license.
involved
on a highway
in the traffic
or who is
(section
316.003
in the space
provided.
[10], F.S.)
This format
is
It must be used even if an out of state
If a driver
has changed
his or her name since
Vehicle
or Pedestrian
Sections
NAME
OF DRIVER
OR PEDESTRIAN
the last issue date of the driver
(Continued)
license,
enter the driver's
first name,
middle
initial, last name,
and name change
in
parentheses.
> Enter the first name , middle
parked.
Do not
enter the name of the driver
when the collision
provided
line in the space
CURRENT
involved
parked
in the traffic
and the driver's
crash was illegally
seat
was unoccupied
is unknown.
unknown
provided.
ADDRESS
CITY, STATE& ZIPCODE
Apt 1n 1fi1fi Anole Street
involved
was legally
if the name of the driver or pedestrian
draw a diagonal
DRIVER OR PEDESTRIAN
CURRENT
ADDRESS
(Number
andSueet))
This space
if the vehicle
if the vehicle
occurred.

initial , and last name of the driver
Trianole.
is used to identify
the current
FL 32000-0000
physical
or mailing
address
of the driver of the vehicle
or the pedestrian
in a traffic crash.
> Enter the current
street
address
or mailing
address,
city, state and
zip code of the driver
or pedestrian
in the space
provided.
> Use the standard two letter postal.service abbreviations for all states (Appendix 2).
DRIVER OR PEDESTRIAN
DATE
DFBIRTH I
I 05-05-46
This space
DA TE OF BIRTH
I
is used to identify
the date of birth of the driver of a vehicle
> Enter the date of birth of the driver

DRIVER
provided
draw a diagonal
LICENSE
or pedestrian
in month,
or the
pedestrian
involved
day and year sequence.
if unknown.
line in the space
provided.
NUMBER
DRIVER
UCENSE
NUMBER
D 001 001 46 001
This space
is used to identify
> Enter the driver

> Enter "none"
license
the driver
number
in the space
number
in the space
provided
provided
license
of the vehicle
driver.
provided.
if the vehicle
driver does not have a driver
if unknown.
18
license.
in a traffic crash.
Vehicle
or Pedestrian
Sections
DRIVER
LICENSE
NUMBER
The driver license

correct
driver
number
number
license
LICENSE
line in the space
is used to identify
number
on any traffic
DRIVER
(Continued)
draw a diagonal
and update
on the traffic crash
citations
issued
provided.
the driver
repori,
history
and ensure
record.
It is very imporiant
that this number
matches
to enter the
the driver
license
as a result of the traffic crash.
STATE
f""STATEl
~
This
>
space
Enter
is
the
states
>
Enter
>
If
used
state
to
that
(Appendix
UK
not
DRIVER
in
identify
the
issued
the
state
that
driver
issued
license
in
the
driver
the
space
license.
provided.
Use
the
standard
two
letter
abbreviations
for
all
2).
the
space
applicable,
draw
LICENSE
provided
if
diagonal
unknown.
line
in
the
space
provided.
TYPE
[tJ
This space
codes
is used to identify
are located
Information"
the type (class)
of driver
on page one of the Florida
Traffic
license
Crash
issued
Report
to the vehicle
(Form
Number
driver.
The driver
HSMV-90003)
license
type
in the "Code
section.
> Enter the driver
license
type in the space
> Enter code 7 in the space
provided
provided..
if the driver
license
type is unknown,
not required
or if a pedestrian
is involved
the traffic crash.
The driver license
type (class)
types of vehicles.
Class A, B, and C driver
driver
license
DRIVER
is required
LICENSE
codes
verify that the driver
for a chauffeur
REQUIRED
licenses
license
in question
are required
has been tested
and licensed
in order to drive commercial
and class E for an operator
or restricted
to operate
vehicles.
certain
A class D
operator.
ENDORSEMENTS
[!J
This space
is used to identify
for the type of vehicle

Crash
Report
(Form
if the driver
being operated.
Number
license
issued
The required
HSMV-90003)
to the vehicle
endorsement
in the "Code
codes
Information"
19
driver
required
are located
section.
any other special
endorsements
Traffic
in
Vehicle
or Pedestrian
Sections
DRIVER
LICENSE
REQUIRED
> Enter a 1 in the space

authorized
to operate
provided
if the driver
a motorcycle

operating
ENDORSEMENTS
a motorcycle
license
or transport
provided
if the driver
without
a motorcycle
presented
hazardous
license
is correctly
endorsed;
for example,
the driver
is
materials.
presented
endorsement
is not correctly
or transporting
endorsed;
hazardous
for example,
materials
the driver
without
is
an
endorsement.
automobile
provided
for private
if an endorsement
is not required;
for example,
the driver
is operating
an
transportation.
ALCOHOL I DRUG TEST TYPE

AlC/DRUGTEST
TYPE
1Blood3Urine
5None
~5
2Breath
4Refused
This space
is used to identify
pedestrian
involved
> Enter the alcoholl
ALCOHOL
the type of test a law enforcement
in a traffic crash
is under the influence
drug test code in the space
officer
of alcohol
provided
required
to determine
or a controlled
for all drivers
if a vehicle
driver or
substance.
and pedestrians.
I DRUG TEST TYPE RESUL TS
IR~I
lillJJ
This space is used to identify the results of any test a law enforcement officer required to determine if a vehicle driver
or pedestrian involved in a traffic crash is under the influence of alcohol or a controlled substance.
> Enter the alcohol/drug
test results in the space (boxes) provided for all drivers and pedestrians.
> Enter UK in the space provided if the alcohol/drug
test results are not known, pending, or if they cannot be
revealed on the Florida Traffic Crash Report (HSMV-90003) for legal reasons.
Update/Continuation
Report (HSMV-90004)
Use the Florida Traffic Crash
to report the results when they are known or it is permissible to reveal
them.
ALCOHOL I DRUG USE

~
This space
being
is used to identify
involved
in a traffic
if a vehicle
driver or pedestrian
crash. The alcohol/drug
use codes
had consumed
are located
Report (Form Number HSMV-90003) in the "Code information" section.

> Enter the appropriate alcohol/drug
use code in the space provided.
20
alcohol
or a controlled
substance.prior
Traffic
Crash
to
Vehicle
or Pedestrian
Sections

ALCOHOL
I DRUG
USE

Report,
provided
Update/Continuation,
PHYSICAL
if the alcohol/drug
HSMV-90004,
test type results
to update
are pending.
the alcohol/drug
Use the Florida
Traffic
Crash
use.
DEFECTS
GJ
This space
is used to identify
The physical
defects
HSMV-90003,
any physical
codes
are located
in the "Code
Information"
physical
defect
defects
attributed
at the bottom
to a vehicle
Traffic
Crash
involved
Report,
in a traffic crash.
Long Form,
section.
code in the space
provided.
RESIDENCE
m
This space is used to identify demographic information about the vehicle driver or pedestrian.
The residence codes are located at the bottom of page one on the Florida Traffic Crash Report, Long Form,
HSMV-90003, in the "Code Information" section.
> Enter the appropriate residence code in the space provided.
RACE
[:J
This space
The codes
"Code
is used to identify
are located
Information"
the race of a vehicle
at the bottom
Traffic
involved
Crash
in a traffic crash.
Report,
Long Form,
HSMV-90003,
in the
HSMV-90003,
in the
section.
code in the space
provided.
SEX
~
This space
is used to identify
The codes
are located
the gender
at the bottom
of a vehicle
"Code Information" section.

code in the space provided.
21
Traffic
involved
Crash
in a traffic
Report,
crash.
Long Form,
Vehicle
or Pedestrian
Sections
INJURY SEVERITY
[IJ
This space is used to identify the severity of injuries sustained by a vehicle driver or pedestrian involved in a traffic
crash. The injury codes are located on page one of the Florida Traffic Crash Report (Form Number HSMV-90003) in
.
the "Code information" section.
> Enter the appropriate injury code in the space provided.
SAFETY
EQUIPMENT
I S.E~IP. I
~
This space
is used to identify
traffic crash.
The safety
HSMV-90003)
equipment
equipment
in the "Code

device
An officer should
the type(s)
of safety
codes
information"
are located
the driver of a vehicle
was using
Traffic
at the time of the
Crash
Report
(Form
Number
section.
safety equipment
code(s)
was in use; for example,

record
equipment
in the
space
seatbeltlshoulder
provided.
harness
Sometimes
more than one type of safety
(code 2) and air bag -deployed
(code 4).
both types of safety equipment
EJECTED
w
This space is used to identify if the driver of a vehicle involved in a traffic crash was ejected.
are located on page one of the Florida Traffic Crash Report (Form Number
HSMV-90003)
The ejection codes

in the "Code information"
section.
> Enter the appropriate ejected code in the space provided
HAZARDOUS
MA TERIALS BEING TRANSPORTED
BCING
~DOUS
TRANSPORTED
MATERLALS
IV.. 2No
This space
[iJ
is used to identify

needed
if any vehicle
(box) provided
to propel the vehicle
if a hazardous
supplying
(box) provided
involved
in the traffic crash was carrying
a hazardous
material
was being carried.
(This does not include
material
was not being carried.
power.)
if a hazardous
22
material
as cargo
the fuel
Vehicle
or Pedestrian
Sections
PLACARDED
I~CARDED
_1
I IV.. 2No [fJI
This space
placard
is used to identify
as required
if the vehicle
by federal
carrying
a hazardous
material
as cargo
displayed
a hazardous
law.
(box) provided
if a hazardous
material
placard
was displayed.
(box) provided
if a hazardous
material
placard
was not being displayed.
There
are two shapes
law to display
carrying
hazardous
hazardous
of placards
a placard
-diamond
that identifies
materials
materials
or rectangular.
the specific
assigned
Vehicles
name of the
in tank cars, cargo tanks,
number
TYPE OF HAZARDOUS
material
to the specific
hazardous
or portable
material
carrying
hazardous
material
cargo.
tanks are required
on placards
are required
In addition,
to display
or orange
MA TERIAL
materials
by
vehicles
the 4 -digit
panels.
IFYES.
INDICATE
NAME
DR4DIGIT
NUMBER
FROM
DlAMDND
ORBOX
I O~~~~~;.~?~~IGIT
NUMBER
FROM
BOTTOr
OFDIAMOND
I explosives
This
space
is used
to identify
> Enter the 4-digit

extracted
number
[!J
what
number
liquid, flammable
at the bottom
HAZARDOUS
of the diamond
the placard
solid, dangerous,
of the diamond,
on the vehicle,
of hazardous
material
or the name of the hazardous
from the middle

is not displayed,
kind
shape
should
oxidizer,
material
placard
being
carried,
poison,
if any
in the space
provided.
or from the rectangular
have one of the following
if it is displayed,
enter the information
was
radioactive,
in the space
names:
or corrosive.
(box) provided.
shape
This information
placard.
explosives,
When
multiple
If the 4-digit
gases,
Enter the 1-digit
is
flammable
number
placards
located
are displayed
from only one of the placards.
MA TERIAL SPILLED
~MATERiAl
)\S HAZARDOUS
SPILLED?
1Ves 2No
This space
is used to identify
compartment
of the vehicle

from the vehicle
if the hazardous
material
( placarded
cargo)
was released
as a result of the traffic crash.
(box) provided
if hazardous
provided
if the hazardous
material
material
tank or
.
was released.
fuel tank.)
from the cargo
was not released.
23
(This does not include
the fuel spilled
Vehicle
or Pedestrian
Sections
RECOMMEND
DRIVER
RE-EXAM
RECOMMEND
DRIVERRE-EXAM.
IF YESEXPlAININ NARRATIVE
1Y.. 2No
This space is used to identify if the driving ability of a vehicle driver is questionable.
> Enter 1 in the space (box) provided if the ability of the driver to operate a vehicle is questionable.
> Enter 2 in the space (box) provided if the ability of the driver to opera'te a vehicle is not questionable.
Section 322.126 (2), (3), Florida Statutes, provides that "any physician, person, or agency having knowledge of any
licensed driver's or applicant's mental or physical disability to drive
Department."
is authorized to report such knowledge to the
The decision to require the driver to submit to another driver license exam is made by the law
enforcement investigator.
In making this assessment, the investigator should take into account
physical defects, coordination, reflexes, and perception.
If a driver's ability is questionable, you must explain your
reasons in the narrative section of the Florida Traffic Crash Narrative/Diagram
DRIVER'S
TELEPHONE
NUMBER
I DRIVER'S
PHONE
NO.
1(
This space
is used to identify
> Enter driver's
telephone
the telephone
number.
number
obvious driver
of the driver.
24
Report (HSMV-90005).
Property
Damage
-Other
Than Vehicle
Section
PROPERTY
#
1
#
2
DAMAGED
OTHER
THAN
VEHICLES
PROPERTY
DAMAGED.OTHERTHANVEHICLES' "RT.AMOUNT
Fence
300.00
I PROPERTY DAMAGED. OTHER THAN VEHICLES
l~oUNT-
OWNER'S
NAME
Calico
ADDRESS
Company
1212
OWNER'S
NAME
driverless
towed vehicle
Diameter
Drive
ADDRESS
GoQet Technical
Rail
.I Guard
This space is used to identify damage to other kinds of property.
I.
CITY
1000.00
4444
Square
Triangle
STATE ZIP
,FL 32000-0000
CITY
Blvd.
TrianQle,
STATE ZIP
FL 32000-0000
Do not record damage to a vehicle,
trailer or
in this section.
> Enter the type of property damaged; for example, fence, telephone pole, mail box, street marker,
animal (cow,
horse, deer,etc.) or damage to cargo that was being carried by another vehicle.
> Enter the estimated damage amount in dollars.
> Enter the owner's name, street or mailing address, city, state,and zip code.
> Use the standard two letter postal service abbreviations for all states (appendix 2).
> Use the Florida Traffic Crash Report, Update/Continuation
instances of damage to property other than vehicles.
25
(HSMV-90004),
to record more than two
Events
(Form
This section
section
is designed
it is important
they are intended

series
of boxes.
the primary
to identify
to remember
to represent.
Some vehicle
vehicle,
Number
Vehicle
HSMV-90003)
pedestrian,
that code entries
and crash scene
must correspond
or pedestrian
or pedestrian
code in the first space
driver,
Section
sections
are identified
data fields may have spaces
(box) and, if applicable,
characteristics.
to the VEHICLE
any subsequent
by the number
(boxes)
codes
When
completing
OR PEDESTRIAN
for multiple
this
SECTION
at the top of each box or

codes.
in the remaining
Always
spaces
enter
(boxes)
The crash scene characteristics data fields do not have a number at the top of a box because they do not apply to a
particular vehicle or pedestrian section. Some of these fields have spaces (boxes) for multiple data codes. Always
enter the primary code in the first space (box) and, if applicable, any subsequent codes in the remaining spaces
CONTRIBUTING
CAUSES DRIVER I PEDESTRIAN
This classification is used to identify improper driver or pedestrian action(s) that may have caused the traffic crash.
> Enter the primary contributing cause code in the first box for each driver or pedestrian; for example, if
section 1 driver ran into the rear of section 2 driver, the investigator might conclude that excessive speed by driver
1 was the main contributing cause rather than following to closely. The investigator would record the primary
contributing
cause in the first box for section 1 driver as 12 and the subsequent contributing cause in the second
box for section 1 driver as 10.

> Enter additional -if applicable -contributing
cause codes (maximum 3) for each driver or pedestrian as needed.
> If code 2, 24 or 77 is used, explain and identify the contributing factors in the Florida Traffic Crash Narrative/
Diagram Report (Form Number HSMV-90005).
> Enter a diagonal line in each box not used.
?I\
Events
(Form
Section
Number
HSMV-90003)
VEHICLE DEFECT
01 NoDefects
02 DefBrakes
03 Worn
I Smooth
Tires
04 Defective
Ilmproper
Lights
05 Puncture
I Blowout
06 Steering
Mech.
~
07 Windshield
Wipers
08 Equipment
I Vehicie 77AllOther
Defect
This
classification
> Enter
the
> Enter
additional
> If code
is used
primary
to identify
vehicle
-if
defect
applicable
77 is used,
vehicle
explain
code
-vehicle
and
identify
mechanical
in the
first
defect
and
box
code
the vehicle
equipment.
for each
for each
defect
defects.
vehicle.
vehicle.
in the
Florida
Traffic
Crash
Narrative/Diagram
Report
(HSMV-90005).
>Enter
a diagonal
line
in each
box
not used.
VEHICLE MOVEMENT
This classification is used to identify vehicle movement of each vehicle at the time of the traffic crash.
> Enter the vehicle movement code in the space (box) provided.
> If code 77 is used, explain and identify the vehicle movement in the Florida Traffic Crash Narrative/Diagram
Report (HSMV-90005).
>Enter
a diagonal
line in each box not used
VEHICLE SPECIAL FUNCTIONS

1 None
~..
~ ~:e Pursuit ro1lro1l~

4Recreational
~~~
5 EmergencyOperation
6 Construction
I Maintenance
This classification
is used to identify
> Enter the special
function
> If code 77 is u~ed, explain

Report
special
operating
code in the space

and identify
conditions
the vehicle
line in each box not used.
involved
in a traffic
crash.
(box) provided.
special
(HSMV-90005).
> Enter a diagonal
of a vehicle
27
functions
in the Florida
Traffic
Crash
Narrative/Diagram
Events
(Form
Section
Number
HSMV-90003)
SOURCE OF CARRIER INFORMA TION

SOURCE OF CARRIER INFORMATION
1 NotApplicable
1
2
3
2 ShippingPapers
3 VehicleSide
4 Driver
."'ho.
This classification is used to identify the means used to obtain the name and address of the motor carrier who was
responsible
for directing
> Enter the carrier
the movement
information
> If code 5 is used, explain

Narrative/Diagram
of cargo or passengers.
code in the space
and identify
Report
the source
(box) provided.
of carrier
information
in the Florida
Traffic
Crash
(HSMV-90005).
POINT OF COLLISION
This classification is used to identify where the first point of contact between vehicles or pedestrians occurred.
> Enter the point of collision code in the space (box) provided.
> Enter a diagonal line in each box not used. .
WORK AREA
01
011101
This classification is used to identify the proximity of a work area to a traffic crash involving a vehicle or pedestrian.
> Enter the work area code in the space (box) provided..
> Enter a diagonal line in each box not used. .
A work
area is defined
boards,
pavement
functions.
markings,
This includes
may have some

area.
as that area designated
work areas
influence
on traffic.
The work area codes
crash scene;
sequence
boundaries
nearby
of events
signage
should
or other traffic control

related
of a designated
to servicing
The presence
used to separate
of workers
?R
workers
tree trimming,
barricades,
drums,
and their equipment
road work,
of the traffic
crash;
is not needed
and entered
vehicles
arrow
from other
and other activities

to define
none (01 ), no work area relevant
one or more of the involved
work area.
cones,
at the time of the crash
manner:
work area in the vicinity
to the traffic crash,
of a flag person,
manholes,
be used in the following
(02), designated
related
by the presence
the work
to the traffic
(03), during
or pedestrians
that
the
were within the
Events
(Form
PEDESTRIAN
Section
Number
HSMV-90003)
ACTION
I PEDESTRIANACTION
01 CrossingNotat Intersection
07 Working
02 Crossingat Mid-blockCrosswalk
In Road,,"
03 Crossingat Intersection
...1
l "I~
08 Standing/Playing
1104
04Walking
Along
Road
With
Traff,c InRoad
05Walking
Along
Road
Against
Traffic
ogStanding
InPedestrian
Island
06Working
onVehicle
InRoad
77AllOther
(Explain
InNarrative)
88Unknown
I
This classification
is used to identify
> Enter the pedestrian

only in the vehicle
a pedestrian,
the section
action code in the space

or pedestrian
place a diagonal
section
was doing prior to the traffic crash.
(box) provided.
it pertains
line in the section
Ensure
too; for example,
that the pedestrian
if section
action
code is placed
1 and 2 are vehicles
1 and 2 boxes and the appropriate
pedestrian
and section
action
code in
3 box.

Report
what the pedestrian
and identify
the pedestrian
action code in the Florida
Traffic
Crash
Narrative/Diagram
(HSMV-90004).
> Enter a diagonal
This classification
is used to describe
> Enter the location
An investigator
specific
type code in the space
should
interpret
FIRST AND SUBSEQUENT
land use characteristics.

(box) provided.
the three location
type codes
as broadly
descriptive
30 RanOffRoad
IntoWater
--Yd
31 Overturned
I
32 Occupant
FellFrom
Yehicie 01
1n
33Tractor/Trailer
Jackknifed
34 Fire
35 Explosion
36 Downhill
Runaway
37 Cargo
LossorShift
38 Separation
ofUnits
39 Median
Crossover
77PJIOther
(Explain
In
Narrative)
~.
This
subsequent
is used
> Enter
the the first(primary)
> Enter
any
subsequent
area.
HARMFUL EVENT (5)
02 Collision
WithMYinTransport(
Head
On) 16MYHitSignI SignPost
03 Collision
WithMYinTransport(
Angle)
17MYHitUtility
PoleI LightPole
04 Collision
WithMYinTransport(
LeftTurn) 18MYHitGuardrail
05 Collision
WithMYinTransport(
Right
Turn) 19MYHitFence
06 Collision
WithMYinTransport(
Sideswipe)20 MYHitConcrete
Barrier
Wall
07 Collision
WithMYinTransport(
Backed
Into)21 MYHitBridge/Pier/AbutmentlRail
08 Collision
WithParked
Car
22 MYHitTreeIShrubbery
o9 Collision
WithMYonRoadway
23 Collision
WithConstruction
Barricade
Sign
10Collision
WithPedestrian
24 Collision
WithTraffic
Gate
11Collision
WithBicycle
25 Collision
WithCrash
Attenuators
12Collision
WithBicycle
(BikeLane)
26 Collision
WithFixed
Object
Above
Road
13
Wrth
Moped
27
HrtOther
Fixed
Object
14Collision
CollIsion
WithTrain
28 MY
Collision
With
Moveable
ObectOnRoad
classification
of the crash
to identify
the
harmful
harmful
first
event
events
and
in the
in the
space
spaces
harmful
events
(box)
provided.
(boxes)
provided
2~
O~
for each
if applicable.
vehicle
or pedestrian
3 is
Events
(Form
FIRST AND SUBSEQUENT
HARMFUL
Number
EVENT(S)
and identify
Section
HSMV-90003)
(Continued)
the harmful
events
in the Florida
Traffic
Crash
Report,
Narrative/Diagram,
HSMV-90005.
> Enter a diagonal
ROAD SYSTEM IDENTIFIER

01 Interstate 07 ForestRoad
02US I 08Private
Roadway
~ 02
03State 77AllOther
(Explain
04County InNarra1ive)
05Laca
06Turn
ikefToli
This classification is used to identify the primary road system on which the traffic crash occurred. Use the highest
road system classification assigned to a particular street, road, or highway; for example, if the crash occurred on a
U. S. Highway which is also a state highway, use the U. S. highway designation.
> Enter the road system identifier code in the space provided.
Narrative/Diagram,
The road system

as the Florida
and identify
the road system
identifier
in the Florida
Traffic
Crash
Report,
HSMV-90005.
identifier
code 06 (turnpike/toll)
should
be entered
for various
urban expressway
toll facilities
Turnpike.
LIGHTING CONDITION
This classification is used to identify the lighting condition at the time of the traffic crash.
> Enter the lighting condition code in the space provided.
ROAD SURFACE CONDITION
r~Ot~SURFACE
CONDITION
02Wet
ro;-
1)3Slippery
02
')4 Icy
77AlIOther
(Explain
InNarralive)
I
This
classification
is used
to identify
the
surface
condition
of the
street,
road,
or highway
at the
time
of the
crash
> Enter the road surface
condition

Narrative/Diagram,
code in the space
and identify
provided.
the road surface
condition
HSMV-90005.
30
in the Florida
Traffic
Crash
Report,
traffic
as well
Events
(Form
Section
Number
HSMV-90003)
WEATHER CONDITIONS
01Clear
02CIoUdY
03Ran ~ 03
04Fog
77~IOther
(Explain
In
Narrative
This classification
is used to identify
> Enter the weather
condition

Narrative/Diagram,
the weather
conditions
at the time of the traffic crash.
code at the time of the crash

and identify
the weather
in the space
conditions
provided.
in the Florida
Traffic
Crash
Report
HSMV -90005.
This classification is used to identify the surface construction of the street, road, or highway on which the traffic crash
occurred.
> Enter the the road surface type code in the space provided.
> If code 77 is used. exolain and identify the road surface type in the Florida Traffic Crash Report,Narrative/Diagram
HSMV-9000S
ROAD
CONDITIONS
AT
01 NoDefects
02 Obslruclion
WithWarning
03 Obslruclion
Wrthout
Warning
04RoadUnderRepairI Construclion
05 LooseSurfaceMaterials
06 Shoulders
-Soft I LowI High
07 HolesI RutsI UnsafePavedEdge
08 Standing
Water
TIME
OF
~08
o9 Worn
I Polished
RoadSurface
77AllOtherEx lainIn NMalive
~09
This
to identify
classification
CRASH
is used
the
road
conditions
of the
street,
road,
or highway
on which
the
traffic
crash
occurred.
> Enter road condition code(s)
in the space(s) provided..
> If code 77 is used, explain and identify the road conditions at time of crash in the Florida Traffic Crash Report,
Narrative/Diagram,
HSMV-90005.
-11
Events
(Form
Section
Number
HSMV-90003)
VISION OBSTRUCTED
01 Vision Not Obscured
02 Inc~ment Weather
03 Parked
I Stopped
Vehicie
04 Trees
I Crops
I Bushes
05 loadOnVehicle
06 Building
I Fixed
Object
07 Signs
I Billboards
08 Fog
I
o9 Smoke 77~I Other
(ExplanI
10Glare
InNarrative
This
classification
> Enter
> If code
is used
the vision
to identify
obstructed
77 is used,
if the
code(s)
explain
and
driver"s
in the
identify
the
or pedestrian"s
space(s)
vision
vision
was
obstructed.
Florida
Traffic
Crash
of the traffic
crash..
provided..
obstruction
in the
Report,Narrative/Diagram
HSMV-90005.
> Enter a diagonal
TRAFFIC
CONTROL
01 No Conuol
02 Special Speed Zone
03 SpeedControlSign
04 SchoolZone
05 TrafficSignal
11 PostedNoU-Turn
06 StopSign
12 NoPassingZone
07 YieldSign
77 PJIOther(ExplainIn
08 FlashingLight
Narrative)
o9Railroad
Signal
10Ofticer/Guard/Fla
erson
This classification
is used to identify
> Enter the traffic control
code(s)
traffic control
in the space(s)
and identify
devices
at the scene
provided.
the traffic control
in the Florida
Traffic
Crash,
Report,
Narrative/Diagram,
HSMV-90005.
> Enter a diagonal
SITE LOCA TION
This classification is used to identify the traffic crash scene in terms of special hazards.
> Enter the site location code in the spaces provided.
> If code 77 is used, explain and identify the site location in the Florida Traffic Crash Narrative/Diagram
HSMV-90005.
32
Events
(Form
TRAFFICWAY
Section
Number
HSV-90003)
CHARACTER
I ri1~:~~~t'0:'~~eICHARACTER
02 Straight-UpgradeI
Downgrade
03 Curve-Level
04.Curve-UpgradeI
n
This classification
is used to identify
> Enter the trafficway
character
the characteristics
code in the space
of the trafficway
provided.
TYPE SHOULDER
l [~~;f~:~ULDER
1'.Paved
02. Unpaved
03. Curb
~
~ 01
This classification
is used to identify
> Enter the type of shoulder
the type of roadway
code in the space
shoulder.
provided.
VIOLA TOR(S)
This classification is used to identify each vehicle driver or pedestrian
who was given a citation for a traffic violation.
by the law enforcement officer who investigated the traffic crash.

> Enter the correct section number, the name of the violator (driver or pedestrian) who was given the traffic
violation citation; the Florida Statute number, the type of charge, and the citation number in the spaces provided.
> If more than four citations are issued list them on the Florida Traffic Crash Report, Narrative/Diagram
(HSMV-90005)
in the violator(s) data fields. Additional violator(s) data fields appear on the Florida Traffic Crash
Report, Update/Continuation
(HSMV-90004).
The section number must at all times correspond to the driver or pedestrian who was given the citation.
If a vehicle
owner or a passenger is given a citation for an infraction, do not place that information in the violator data fields.
Explain the owner or passenger infractions in the narrative portion of the Florida Traffic Crash Report,
Narrative / Diagram,
(HSMV-90005).
33
~
PASSENGER'S NM1E
~
iSECiii
CITY & STATE
PASSENGER'S NAME
CURRENT ADDRESS
CITY & STATE
DATE OF BIRTH lRACEI~!-COC-!'""INJ
ZIP CODE
!
!
DATEOFBIRTHlRACEISEX IlOC IINJ I~~I
EJECT.
fEJECT:-
PASSENGER'S
NAME
CURRENT
ADDRESS
CITY
& STATE
ZIPCODE
DATEOFBIRTH
EJECT.
EJECT.
IsEi:iI
I
PASS#"
."
SECTION #
NAME
OF
VIOLATOR
FLSTATUTENUMBER
CHARGE
NAME OF VIOLATOR
Fl STATUTE NUMBER
CHARGE
WITNESS
NAME
FIRSTAIDGIVENBY- NAME
ZIPCODE ."ITNESS
NAME
(2)
CURRENT
ADDRESS
[LOC"
I.
...
CITATION
NUMBER
CITATION NUMBER
.CITY
&STATE
ZIPCODE
1. Physician or Nurse 2. Paramedicor EMT 3. Police

4. Certified 1stAider
WAS
IFNO. TH
INVESTIGATION 1.YES
MADEAT SCENE? 2. NO
INVESTlGATORRANK& SIGNATURE
HSMV-90005 (Rev. 1102)
I,
CITY
&STATE
CURRENT
ADDRESS
5. Other
IF YES.BYWHOM?
11NVESTIGATINGAGENCY
2. OTHER
~
CUD ""
on "T'i"q
1 YES
2 NO
ID/BADGE
NUMBER
Page
Of
Narrative
(Form
I
Number
Diagram
HSMV-90005)
This report is used to describe and diagram the traffic crash scene, and to identify passengers.
conjunction with the Florida Traffic Crash Report, Long Form, HSMV-90003.
It is always used in
Extreme care should be taken to ensure
that the date of the traffic crash, the county / city code, the investigating agency report number, and the HSMV
pre-printed crash report number on the narrative / diagram and the long form are identical.
TIME EMS NOTIFIED
(Fatalities
only)
TIME
EMS
NOTIFIED
(FATALITIES
ONlY)
10:15
WAM D PM
Enter the time of day that emergency
medical
services
were notified
of the traffic crash
Midnight is considered AM and noontime is considered PM.

NOTE: Use the 12 hour clock system to identify the time of the crash.
Do not use the 24 hour clock system (aka
military time).
TIME EMS ARRIVED
(Fatalities
only)
TIME
EMS
ARRIVED
(FATALmES
ONLY)
10:15
~AM D PM
Enter the time of day that emergency
medical
services
arrived
at the scene
of the traffic
crash.
* Midnight is considered AM and noontime is considered PM.

NOTE: Use the 12 hour clock system to identify the time you were notified of the traffic crash
Do not use the 24
hour clock system (aka military time).
DATE
OF CRASH
I DATE
D~CRASH
I
1011101021
Enter the date of the traffic
crash
in month,
> Display
the month
> Display
the day by using the numbers
> Display
the appropriate
by using the numbers
> The date of the crash

Long Form,
day, and year order in the following

01 through
01 through
manner:
12.
31.
year as required.
must be identical
to the date of the crash on page one of the Florida
HSMV-90003
1.1
Traffic
Crash
Report,
Narrative
(Form
COUNTY
I CITY
space
Number
HSMV-90005)
CODE
I COUNTY.
~ CI:V_C?DE
I
13 151
This
/ Diagram
I
I
is used
to identify
the
county
and
city
(aka
place)
codes.
Please
refer
to appendix
1 for
the correct codes.

> Enter the county
> The county
and city code as required.
/ city code must be identical
to the county
/ city code on page one of the Florida
Traffic
Crash
Report,
Long Form, HSMV-90003
INVESTIGATING
AGENCY
REPORT
NUMBER
INVEST.
AGENCY
REPORT
NUMBER
01-011234567-01
This space
-~
is used to identify
the investigating
> Enter the report or file number

> The investigating
agency
of the Florida Traffic
HSMV
CRASH
REPORT
I
112345678
This
space
appears
is used
on
>
Enter
>
The
each
the
Traffic
identify
Florida
HSMV
pre-printed
Florida
to
assigned
report
Crash
law enforcement
the
Traffic
pre-printed
crash
Crash
report
Report,
report or file number.
by the agency.
number
Report,
agency's
must be identical
Long Form,
to the investigating
agency
report
number
on page one
HSMV-90003
NUMBER
I HSMVCRASHREPO!TNUM~ER-
,.
eight
Crash
crash
number
Long
digit
pre-printed
Report,
report
must
Form,
crash
Long
form,
report
number.
A pre-printed
crash
report
number
HSMV-90003.
number.
be
identical
to
HSMV-90003
35
the
pre-printed
crash
report
number
on
page
one
of the
Narrative
(Form
Number
Diagram
HSMV-90005)
NARRA TIVE
Describe what happened, and ensure that the correct section number is used when referring to specified vehicles,
drivers, or pedestrians.
Use the Florida Traffic Crash Report, Update / Continuation,
HSMV-90004
, if additional
narrative space is needed.
PASSENGERS
lSEC#
IPASS#I
PASSENGER
'8NAME
11 11 I Jimmy D. Doe
CURRENT
ADDRESS
Apt. 10' 1515 Angle Street
CITY
&STATE
Triangle, FI
This space is used to identify all passengers riding within or on a vehicle.

pick-up truck and people riding illegally on the vehicle.
This includes people riding in the back of a
The passenger information must be provided for all injured
and uninjured passengers.

> Enter the correct section number. This number must be identical to the vehicle or pedestrian section number
controlling the vehicle the passenger was riding in or on at the time of the traffic crash.
> Enter the passenger number(s) for all passengers riding in or on the same vehicle
> Enter the name, current address, city and state, and zip code for each passenger.
> Enter the date of birth for each passenger.
> Enter the elements for identifying the race, sex, location, injury, safety equipment, and ejected codes for each
passenger.
The codes are located on page one of the Florida Traffic Crash Report, Long Form, HSMV-90003 in
the " Code Information" section.

> Use the Florida Traffic Crash Report, Update I Continuation, HSMV-90004,
information is required.
't~
if more space for passenger
Narrative
(Form
I
Number
Diagram
HSMV-90005)
This classification is used to identify each vehicle driver or pedestrian
who was given a citation for a traffic violation
by the law enforcement officer who investigated the traffic crash.

> Enter the correct section number, the name of the violator (driver or pedestrian) who was given the traffic
violation citation; the Florida Statute number, the type of charge, and the citation number in the spaces provided.
> Additional violator(s) data fields appear on the Florida Traffic Crash Report, Update/Continuation
(HSMV-90004).
The section number must at all times correspond to the driver or pedestrian who was given the citation.
If a vehicle
owner or a passenger is given a citation for an infraction, do not place that information in the violator data fields.
Explain the owner or passenger infractions in the narrative portion of the Florida Traffic Crash Report,
Narrative / Diagram,
WITNESS
(HSMV-90005).
NAME
WITNESS
NAME
(1)
CURRENT
ADDRESS
None
This space
is used to identify
> Enter the information
FIRST
AID
GIVEN
anyone
requested
who witnessed
in the same
the traffic
manner
1. Physician
or Nurse2. Paramedic
or EMT 3. Police
James Bond
4. Certified1stAider 5. Other
>
space
Enter
FIRST
is used
the
name
AID GIVEN
previously
described
for similar
records.
BY
FIRST
AIDGWEN
BY-NAME
This
crash
to identify
of the
if first
person
aid was
administering
administered
first
at the
aid and
the
scene
code
of the traffic
that
best
crash
identifies
their
certification
level.
BY
I INJURED
TAKEN
TO;
I Memorial'
This space
is used to identify
the name of the hospital
or facility
passengers.
> Enter the name as appropriate.
~7
that received
injured
drivers,
pedestrians,
or
Narrative
(Form
I
Number
Diagram
HSMV-90005)
BY -NAME
BY.NAME
Memorial Ambulance
This space
is used to identify
the name of the person
or agency
that transported
the injured
drivers,
pedestrians,
passengers.
>
Enter
the
name
as appropriate.
WAS INVESTIGATION
WAS
INVESTIGATION
1.YES
0]1
MADE AT SCENE
IFNO.THEN
WHERE?
&1
~
MADEATSCENE?
2.NO
This space
is used to identify
if the investigation
was made at the traffic crash
scene.
> Enter the number
1 in the space
provided
was made at the scene.
> Enter the number
2 in the space
provided
if no and then the name of the location
where
the investigation
place.
IS INVESTIGATION COMPLETE
[I] IFNO.THEN
WHY?
IS
INVESTIGATION
I. YES 1
""""' r:T~? 2.NO
This space
is used to identify
is complete.
> Enter the number
1 in the space
provided
> Enter the number
2 in the space
provided
if no and
DATE
is complete.
the reason
why the investigation
is not complete,
OF REPORT
ID~~OFiE~;T I 02
This space
is used to identify
the date the traffic crash
> Enter the date the report was completed
in month,
report was completed..

day, and year sequence.
S TAKEN
1.YES ~
2.NO L!.-J
This space
is used to identify
> Enter a 1 if photos
if photographs
were taken
> Enter a 1 if the investigating
were taken at the scene
or a 2 if they were not taken

agency
took the photos
in the space
or a 2 if not.
38
of the traffic
crash
provided.
and if so, by whom.
took
or
Narrative
(Form
I
Number
BY -NAME
INVESTIGATOR
-RANK
&SIGNATURE
Cpl. Bob Baker
This space
Diagram
HSMV-90005)
DEPARTMENT
Triangle Police Department
is used to identify
the name of the investigator
and the investigating
law enforcement
agency.
> Enter the your rank and name and sign the report..
> Enter your ID or badge
number.
> Enter the name of your department
and place an X in the correct
box.
DIAGRAM
This space
is used to draw the traffic crash
procedures
of the submitting
agency
scene.
for matters
The diagram
of this type.
39
should
be prepared
based
on the standard
operating
DO NOT WRITE IN THIS SPACE
01 NoImproperDrivingI Action
02 Careless
Driving
(ExplainIn Narrative)
')4
Improper
Backing
03 FailedTo YieldRight-of-Way
D D
",
01 NoDefects
rn
02 Defective
Def Brakes
04
I Improper
03 Worn I Smooth
Tires
0:::3
05 ImproperLaneChange
Lights
'16 ImproperTurn
05 Puncture
I BkJwout
')7 Alcohol-UnderInfluence
06 SteeringMech
08 Drugs-UnderInfluence
07 Windshield
Wipers
o9 Alcohol& Drugs.UnderInfluence
08 EquipmentlVehicle
10 Followed
TooClosely
Defect
11 Disregarded
TrafficSignal
12 Exceeded
SafeSpeedLimit
19 ImprOper
Load
01 On Road
13 Disregarded
StopSign
20 Disregarded
OtherTrafficControl02 NotOn Road
14 FailedTo MaintainEquipIVehicle 21 DrivingWrongSideI Way
03 Shoulder
15 ImprOper
Passing
22 FleeingPolice
04 Median
16 DroveLeftof Center
23 VehicleModi1ied
05 TurnLane
17 Exceeded
StatedSpeedLim~
24 DriverDistraction
18 Obstructing
Traffic
77 All Other(ExplainIn Narrative) I '11 None
02 Noarby
03 Entered
DO
D ~O
OD
DO
01 StraightAhead
02 MaklngLeftTUrn
SlowingI StoppedI Stalled
03
04
Backing
..
77AllOther
15 CollisionWiUlAnimal
29 MVRanIntoDitch/Culvert
16 MVHrtSignI
30 Ran Off Road Into Water
Transport(
Head On)
Sign Post
17 MVHrtUtilityPoleI LightPole
18 MVHrtGuardrail
19 MVH,tFence
20 MVHrtConcreteBarrierWall
21 MVHrtBridgeIPier/AbutmentlRail
22 MVHrtTreeIShrubbery
23 CollisionWithConstruction
BarricadeSign
24 CoII,slon
W,thTrafficGate
25 CollisionWith CrashAttenuators
26 CollisionWithFixedObjectAboveRoad
27 MVHitOtherFixedObject
28 CollisionWiUlMoveable
ObectOn Road
rl
;Q
SPECIAL
1 None
2 Farm
43 Recreational
PolicePursuit
D':.'
D D
DO
SOURCE OF CARRIER
1 NotApplicable
2 ShippingPapers
3 VehicleSide
4 Driver
, ~._-
INFORMATION
nD nD
00
DO
n'
LJ
DO
DD
31 Overturned
32 OccupantFellFromVehK:le
33 Tractor/Trailer
Jackknifed
34 Fire
35 Explosion
DO
c
36 DownhillRunaway:
37 CargoLossor Shift
38 Separauon
of Units
39 MedianCrossover
:.
77 AJIOther
(ExplainIn
Narrauve)
FUNCTIONS
5 Emergency Operation
6 Construction I Maintenance
07 Working
02 Crossingat Mid-blockCrosswalk
In KoaO
03 Crossingat Intersection
08 Standing/Playing
04 WalkingAlongRoadWithTraffic
In Road
05 WalkingAlongRoadAgainstTraffic o9 StandingIn Pedestrian
Island
06 Workingon VehicleIn Road
77 All Other(ExplainIn Narrative)
88 Unknown
')2 Collision
With MVin
r1
u' -
05 MakingRightTurn
06 ChangingLanes
07 EnteringI LeavingI ParkingSp~e 11 Passing
06 ProperiyParked
12 Dnverless
or
o9 Improper1y
Parked
RunawayVehicle
10 MakingU-Turn
77 All Other(Explain
In Narrative)
01 CollisionWiUlMYin Transport(RearEnd)
1)3CollisionWithMVinTransport(
Angle)
04 ColusionWith
MVinTransport(LeftTurn)
05 CoII,slon
WithMVInTransport(RightTurn)
06 CollisionWithMVin Transport(Sideswipe)
07 CollisionWithMVin Transport(BackedInto)
08 Colusion
WiUlParkedCar
09 CollisionWiUlMVonRoadway
10 CoII,slon
W,UIPedestrian
11 CollisionWiUlBicycle
12 CollisionWiUlBicycle
(BikeLane)
13 CollisionWithMoped
14 CollisionWithTrain
VEHICLE
oc
~
~
N~
DD
..
..
{ ADDITIONALNARRATIVE)
SEC# IPAss#1 PASSENGER'S NAME
CURRENT ADDRESS
CITY& STATE
iSEC#IPASS#! PASSENGER'S NAME
CURRENT ADDRESS
CITY & STATE
"ZiPC"6ijE
isec# IpASS#1 PASSENGER'S NAME
CURRENT ADDRESS
CITY & STATE
ZIP CODE
~
'ir;
I~I
O
-I
ZIPCODE
! DATEOFBIRTHlRACEISEX I LOC i,NJ i- R F~
EJECT:
SEGTiON#
NAME OF VIOlA TOR
Fl STATUTE NUMBER
CHARGE
CITATION NUMBER
SECTION#
NAME OF VIOlA TOR
FL STATUTE NUMBER
CHARGE
CITATION NUMBER
Pace
Of
Update
/ Continuation

This report is used to update or upgrade information previously recorded on a Florida Traffic Crash Report, Long
Form, HSMV-90003. This report also functions as a continuation report to identify additional vehicle, driver,
pedestrian, passenger, property damage other than vehicles, and crash scene characteristics if more than three
vehicles or pedestrians are involved in the same traffic crash. When completing this section it is important to
remember that code entries must correspond to the VEHICLE OR PEDESTRIAN SECTION they are intended to
represent.
Refer to the procedures for entering data on the long form and narrative / diagram when completing the
UPDATE
FLORIDA
TRAFFIC
CKJ UPDATE
CRASH
D
REPORT
~,
CONTINUATION
MAIL
TO:DEPT.
OFHIGHWAY
SAFETY
& MOTOR
VEHICLES.
TRAFFIC
CRASH
RECORDS,
NEILKIRKMAN
BUILDING,
TALLAHASSEE,
FL32399-0500
Provide
updated
the following
information
information
and
data
when
to link
this
the
form
update
is used
to update
/ continuation
report
a vehicle
with
the
or pedestrian
section.
long
narrative
form
and
Only
the
/ diagram
are
required.
> Enter
an X or a check
mark
in the
box
marked
"Update."
> Enter the Date of the Crash. The date must be identical to the date of the crash on the Florida Traffic Crash Report
Long Form, HSMV-90003 and the Florida Traffic Crash Report, Narrative / Diagram Report, HSMV-90005.
> Enter the County I City code. The code must be identical to the county I city codes on the Florida Traffic Crash
Report Long Form, HSMV-90003 and The Florida Traffic Crash Report, Narrative I Diagram Report, HSMV-90005
> Enter the Investigating Agency Report Number. The number must be identical to the investigating agency report
number on the Florida Traffic Crash Report Long Form, HSMV-90003 and The Florida Traffic Crash Report,
Narrative I Diagram Report, HSMV-90005.
> Enter the eight digit pre-printed HSMV Crash Report Number. The number must be identical to the pre-printed
HSMV Crash report number on the Florida Traffic Crash Report Long Form, HSMV-90003 and The Florida Traffic
Crash Report, Narrative / Diagram Report, HSMV-90005.
> Enter the vehicle or pedestrian section number (1 ,2,3,etc) that you intend to update.
Enter the updated information; for example, alcohol/drug
> Enter
rank
and
sign
the
> Enter your ID / Badge

> Enter
the
name
of your
test results from .000 to .010
report.
number
department
and
place
an X in the
40
appropriate
box
Update
/ Continuation
(Form
lSEC#
IPASS#I
PASSENGER'S
NAME.
11 11
Number
HSMV-90004)
CITY
& STATE
CURRENTADDRESS
ZIPCODE
Provide
the following
information
information
when this form is used to update
and data to link the update
I continuation
a passenger
record.
Only the updated
report with the long form and narrative
I diagram
are
required.
> Enter an X or a check mark in the box marked "Update."

Enter the Date of the Crash. The date must be identical to the date of the crash on the Florida Traffic Crash Report
> Enter the County I City code. The codes must be identical to the county I city codes on the Florida Traffic Crash
Report Long Form, HSMV-90003 and The Florida Traffic Crash Report, Narrative I Diagram Report, HSMV-9000S
Narrative / Diagram Report, HSMV-90005.
> Enter the eight digit pre-printed
HSMV Crash Report Number.
The number must be identical to the pre-printed
HSMV Crash report number on the Florida Traffic Crash Report Long Form, HSMV-90003
and The Florida Traffic
Crash
Report,
Narrative
> Enter
the
section
and
> Enter
rank
and
> Enter
your
ID / Badge
> Enter
the
sign
name
I Diagram
passenger
the
Report,
HSMV-90005.
number
and
and
place
the
updated
information.
report.
number
of your
department
# PROPeRTY
DAMAGeD
-OTHeR
THAN
VEHICLeS
an X in the
appropriate
OWNeR'S
NAMe
box.
"SmE-;.".
-cff'i"
.,-,
1
Provide the following information when this form is used to update a property damage other than vehicle record.
Only the updated information and data to link the update / continuation report with the long form and narrative/diagram
are required.
> Enter an X or a check mark in the box marked "Update."
> Enter the Date of the Crash. The date must be identical to the date of the crash on the Florida Traffic Crash Report
> Enter the County
Report
I City code. The code
Long Form,
HSMV-90003
must be identical
and The Florida
Traffic
to the county
Crash
Report,
I city codes
Narrative
on the Florida
I Diagram
Traffic
Report,
Crash
HSMV-9000S
41
Update
(Form
Continuation
Number
HSMV-90004)
> Enter
>
the
section
number
Enter
rank
and
sign
the
> Enter
your
ID / Badge
and
the
updated
information
report.
number
> Enter the name of your department and place an X in the appropriate box.
CONTINUA
TION
FLORIDA
D
TRAFFIC
UPDATE
CRASH
[X]
REPORT
CONTINUATION
MAILTO' DEPTOFHIGHWAY
SAFETY& MOTORVEHICLES,
TRAFFICCRASH
RECORDSNEILKIRKMAN
BUILDING,
TALLAHASSEE,
FL 32399-0500
Provide the following information when this form is used as continuation report.
> Enter an X or a check mark in the box marked "Continuation"
> Enter the Date of the Crash.
Long Form, HSMV-90003
The date must be identical
and the Florida
Traffic
Crash
to the date of the crash on the Florida

Report,
Narrative
/ Diagram
Report,
Traffic
Crash
Report
HSMV-90005.
> Enter the County / City code. The code must be identical to the county / city codes on the Florida Traffic Crash
Report Long Form, HSMV-90003 and The Florida Traffic Crash Report, Narrative / Diagram Report, HSMV-9000S
> Enter the Section Number (4,5 etc) for the vehicle or pedestrian.
> Enter the additional vehicle, pedestrian, property damage-other
than vehicle, or passenger information as
previously outlined in this manual

> Enter
rank
and
sign
the
> Enter your ID / Badge
report.
number
> Enter the name of your department and place an X in the appropriate box.
42
I DIAGRAM
.I
01 No Improper Driving I Action
02 Careless Driving (Explain In Narrative)
ODO
[IJ
[1]
01 No Defects
I.2.J
02 Del.Brakes
03 WornI SmoothTires
04 DefectiveIlmproper
Lights
05 Puncture/Blowout
06 SteeringMech
07 Windshield
Wipers
08 Equipment
I Vehicle
Defect
[1]
03 FailedTo YieldRight.of- Way

'14 ImproperB~king
05 ImproperLaneChange
06 ImproperTurn
07 Alcohol-UnderInfluence
08 Drugs. UnderInfluence
o9 Alcohol& Drugs.UnderInnuence
10 FollowedTooClosely
11 Disregarded
TrafficSignal
12 ExceededSafeSpeedLimit
191mproperLoad
01OnRoad
13 Disregarded
StopSign
20 Disregarded
OtherTrafficControl02 NotOn Road
14 FailedTo MaintainEquipIVehicle 21 DrivingWrongSideI Way
03 Shouider
15 Drove
Improper
Passln9
22 Vehicle
FleeingModilied
Police
04 Turn
Median
16
Left
of Center
23
05
Lane
000
ODO
17 ExceededStatedSpeedLimit
18 Obstructing
Traffic
VEHICLE MOVEMENT
01 Straight Ahead
ill
---02
77All Other
ODO
24 DriverDistraction
77 All Other(ExpiainIn Narrative) 01 None
'12 Nearby
03 Entered
Dm
11 CollisionWithBicycle
25 CollisionWith CrashAttenuators
39 MedianCrossover
26
77
Lane)
13 CollisionWithMoped
'4 CollisionWithTrain
II 01
No DefectsWrthwarning
02 Obstruction
03 Obstruction
WithoutWarning
'14RoadUnder
Repair
I Construc~on
05 LooseSurfaceMaterials
06 Shoulders-Soft/low/High
107 HolesI RutsI UnsafePavedEdge
08 StandingWater
09 WornI PolishedRoadSurface
77 All Other(ExplainIn Narrativ~
Collision
With
Fixed
Object
Above
Road
27 MYHitOtherFixedObject
28 CollIsionWithMoveable
ObjectOn Road
D
O
01 VIsion
NotWeather
Obscured
02
Inclement
03 Parked/StoppedVehicle
04 Trees
I Crops
/ Bushes
All
Other
(Explain
[11
'
O rn
'.
3 Police Pursuit
4 Recreational
11]
(1]
DDD
5 Emergency
Operation
6 Con..."'"nn I 'hin+Onon,"
-1S~O~~~~c~~eCARRI~ INF~MAT~
2 ShippingPapers
3 VehicleSide
01
[1]
.05
Dm
-06
ill
1 Pri~arily
05 LoadOnVehicle
06 BuildingI FixedObject
07 SignsI Billboards
08 Fog
o9 Smoke 77 AIiOther(Explain
10 Glare
In Narrativ~
rn
04
77
03 Speed
Control
Sign
04 School
Zone
Icy
AIiOther
04
.77
01 Slag/Gravel/Stone
02 Bnck/Block
03
Blacktop
Fog
04
Concrete
AIiOther
05
Din
c---'
77 All Other(Expl..nIn
"'
0\
01
NotAtlntersection/RRX-ing
/8li
02 At
Intersection
01.Straight
02.
Straight-Upgrade
Level /
03 Influenced
ByIntersection
04 Dnveway
Access
Downgrade
03,Curve
-levei
11 PostedNoU-Tum 05 Railroad
11 PrivateProper1y
12 NoPassingZone 06 Bridge
12 TollBooth
77 All Other(ExplainIn 07 EntranceRamp 13 PublicBusStopZone
08 Flashing li9ht
Narrative)
08 ExitRamp
77All Other(ExplainIn
09 RailroadSignal
09 Parkinglot- Public Narrative)
10 OfficerI GuardI Flagperson
10 ParkingLot-Private
(ExplaInIn
Narra"...'
Residential
J
L
1 OpenCountry
102 Dusk
03 Dawn
04 Dark(StreetLight)
05 Dark(NoStreetlight)
00 I'n"nn,..n
01 Clear
02 RaIn
Cloudy
03
(ExplainIn Narra~ve)
01
NoControl
02 Special
SpeedZone
05 TrafficSignal
06 StopSign
07 YieldSign
01 Dry
02 W,et
03
Slippery
2 Primarily.
Business I
-1-UGH.1NG
CONDITION
l 01 Da:!;~".
02 us.
I 08 PnvateRoadway
03 State
77 All Other(Explain
04 County
In Narrative)
lOCal.
Turnpike/Toll
..'.
In
NMative)
ROAOSYSTfM
01 Interstate 07 Forest
Road
0
(Bike
[j]
04 WalkingAlongRoadWIthTraffic
In Road
05 WalkingAlongRoadAgainstTraffic 09 StandingIn Pedestrian
Island
06 Workingon VehicleIn Road
77 All Other(ExplainIn Narrative)
88 Unknown
31 Ovenurned
32 OccupantFellFromVehic~
33 Tractor/TraiierJackknifed
34 Fire
35 Explosion
36 DownhillRunaway
37 Separation
CargoLossof
orUnits
Shift
38
Bicycle
1 None
2 Farm
0 0 0
03 CollisionWrthMYin Transpon(Angle)
17 MYHitUtilityPoleI LightPole
04 CollisionWithMYin Transpon(LeftTurn) 18 MVHitGuardrail
05 CollisionWithMYin Transpon(RightTurn) 19 MYHitFence
06 CollisionWithMYin Transpon(Sideswipe) 20 MVHitConcreteBarrierWall
07 CollisionWithMYin Transpon(BackedInto) 21 MVHitBridgelPierlAbutrnenl/Rail
08 CollisionWithParkedCar
22 MVHitTree/Shrubbery
09
CollisionWith
WithPedestrian
MVon Roadway
23 Collision
CollisionWith
WithT
Construction
Sign
10 Collision
24
rafficGate Barricade
With
ill
07 Working
[IJ
02 Crossing
Crossingat
at Intersection
Mld-block
Crosswalk 08 In
Road
03
Standing/playing
29MVRanIntoDitch/Culven 0]
30 RanOffRoadIntoWater
Collision
[1]
~ ~~:~
FVFNTIS\
01 Collision
WrthMVinTranspon(
RearEnd) 15Collision
WithAnimal
02 CollisionWrthMVinTranspon(Head
Dn) 16MYHitSignI SignPost
12
[IJ
SlowingI StoppedI Stalled ~

-03 MakingLeftTurn
04 Backing
-05 MakingRightTurn
11 Passing
06 ChangingLanes
12 Driverlessor
II 07 EnteringI LeavingI ParkingSpace RunawayVehicle
I 08 ProperlyParked
77 Ali Other(Explain
o9 Improperly
Parked
In Narrative)
10 MakingU-Turn
04,Curve-Up9radeI
Downor.rl.
i n~ R
01.Paved
02.Unpaved
03.(:lIrh
D
,
"
Fiflure4-2
Law
Enforcement
Short
Form
Report

This form is used as a Law Enforcement Short Form Report, Driver Report of Traffic Crash, or Driver Exchange of
Information form. Time and location data are entered based on the instructions previously outlined for the long form
report. The vehicle and pedestrian sections should be completed based on the information requested for each field.
Completion of the events data (back of sheet 1) of the short form are the same as the long form.
This form is used to report all traffic
Crash
Report,
officer
at the scene
only required
agency.
required
crashes
HSMV-90003,
to the department
bya
of the traffic crash decides
to fill in the shaded
Place an X or check
Form Report.
distribute
Long Form,
areas.
by you report completed

copies
to report
Additional
that do not require

officer.
data can be entered
agency."
if it is required
1 that identifies
mark in the box at the bottom
by law enforcement
(sheets
completion
A short form report
the traffic crash to the department.
mark in the box at the top of sheet
Also, place an X or check
the remaining
law enforcement
of sheet
of a Florida
is prepared
The reporting
by the reporting
Traffic
(sheet
1) if the
officer
the form as a Law Enforcement

1 that states
After completion
"no further
the investigating
is
officer's
action
officer
Short
is
should
2, 3 and 4) to the driver(s).
If the officer decides not to report the crash, then the driver(s) must complete the form and send a copy to the
department. The officer should remove sheet 1, and place an X or check mark in the box at the top of the sheet 2 that
identifies the report as a Driver Report of Traffic Crash. Also place an X or check mark at the bottom of the sheet 2
that states "you must read and comply with the instructions on the back of this page." This statement refers to the
instructions on the back of sheets 2. 3 and 4.
Use this form as a driver exchange of information when a long form is completed
43
Appendix
County
and City / Place

Codes
Oade County
Aventura
Bal Harbor
Bay Harbor Islands
County
01
01
01
Biscayne
Gardens
01
Biscayne
Park
01
Browns Village
01
Bunche Park
01
Carol City
01
Coconut Grove
01
Coral Gables
01
Coral Way Village
01
Cutler Ridge
Oade Co. School PO
01
El Portal
01
Fllnternational
Un.
01
01
Florida City
01
Golden Beach
01
Golden Glades
01
Goulds
Hialeah
01
01
Hialeah Gardens
Homestad AFB
Homestead
01
01
01
Indian Creek Village
01
Islandia
01
Kendall
01
Key Biscayne
Leisure City
01
Medley
Miami
Miami Beach
01
Miami Lakes
01
Miami Shores
01
Miami Springs
Miami TP
01
Micc. Indian Res.
01
01
01
01
01
Naranja
North Bay
01
North Bay Village

North Miami
01
North Miami Beach
01
Norwood
01
Ojus
Olympia Heights
Opa Locka
01
Palmetto
01
01
Estates
Perrine
Pine Crest Village
01
01
01
01
01
City
29
30
32
33
34
47
45
37
36
38
40
42
31
44
99
46
48
50
52
54
56
59
58
60
61
63
62
65
64
66
68
69
70
72
67
73
74
76
78
80
82
71
83
77
84
79
85
35
County
01
City
81
Richmond Heights
South Miami
01
86
01
87
South Miami Heights
01
95
Sunny Isles
01
88
Surfside
01
89
Sweetwater
01
90
Uleta
01
96
Unicorporated
Unincorporated
01
00
01
91
01
94
Virginia Gardens
01
92
West Miami
01
93
Westview
01
98
01
97
Atlantic Beach
02
30
Baldwin
02
32
Bayard
Cecil Field NAS
02
34
02
02
48
Pinewood
University
Count
of Miami
Westwood
Lakes
Duval County
Dinsmore
36
02
38
40
Jacksonville
Jacksonville
Beach
02
Jacksonville
NAS
02
50
Jacksonville
University
02
46
Mandarin
Mayport NAS
02
42
02
Neptune Beach
02
52
44
Unicorporated
Un. Of North Florida
02
00
02
60
03
39
38
46
47
48
49
44
58
51
40
42
43
45
41
50
Hillsborough
Brandon
Clair-Mel
E. Lake Orient Park
03
Egypt Lake
03
Lake Carroll
03
Lake Magdalene
03
Leto
MacDil1 AFB
03
03
03
Palm River/Clair
Mel
03
Plant City
03
Progress Village
Rocky Creek
03
Ruskin
Sweetwater
03
Tampa
A-1
Creek
03
03
03
County
and City / Place

Codes
Hillsbaraugh
(Cant.
Tampa Int. Airport
County
03
City
60
03
52
Unincorporated
Un. Of South Florida
03
00
Frostproof
Haines City
03
54
Highland
Un. Of Tampa
03
56
Hillcrest
Temple
Terrace
Fort Meade
Pinellas
Belle air
Belle air Beach
Belle air Bluffs
Clearwater
Dunedin
Eckerd
College
Gulf port
Indian
Rocks
Beach
Indian Shores
Kenneth
City
Largo
Lealman
Maderia
Beach
N. Redington
Beach
Oldsmar
Pinellas
Co Campus
Pinellas
Park
Redington
Beach
Redington
Shores
Safety
P D
Harbor
Seminole
Park
Seminole
Park
South
Pasadena
St. Petersburg
St. Petersburg
Beach
St.Pete/Clearwater
Air.
Tarpon Springs
Treasure Island
Unincorporated
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
30
32
34
36
38
72
40
42
74
44
46
47
48
50
52
78
54
56
58
60
61
76
62
64
66
65
68
70
00
05
05
05
05
05
05
05
05
05
05
30
32
31
37
34
36
38
40
33
64
Bartow
Combee
settlement
Cypress
Gardens
Davenport
Dundee
Eagle
Lake
Eagle Peak
East Auburndale
Florida
Southern
Coil
Heights
lake
Alfred
lake
Hamilton
lake
Holloway
lake
Wales
lakeland
Mulberry
Polk City
Unincorporated
Wahneta
West Winter
Haven
Winston
Winter
Palm
Haven
Belle Glade
Belvedere
Homes
Boca Raton
Boynton
Beach
Briny Breezes
Cloud
lake
Delray
Beach
FI Atlantic
Un.
Glen Ridge
Golf Village
Golfview
Greenacres
City
Gulf Stream
Haverhill
Highland
Beach
Hypoluxo
Juno Beach
Jupiter
Jupiter
Inlet Colony
Lake Clark Shores

Lake Park
Lake Worth
Lantana
Manalapan
Mangonia Park
North Palm Beach
Ocean
Pahokee
A-?
City
44
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
28
30
31
32
34
36
38
40
95
41
24
26
42
44
46
48
50
52
54
56
58
60
62
64
66
68
70
72
74
42
46
43
47
48
50
53
54
52
56
60
00
61
55
35
62
Beach
Atlantis
Polk
Auburndale
Park Village
County
05
05
05
05
05
05
05
05
05
05
05
05
05
05
05
05
05
Ridge
County
and City I Place

Codes
Palm
Beach
(Cant.)
Palm Beach
Palm Beach AFB
Palm Beach
Gardens
Palm Beach
School
Palm Beach
Shores
Bd
Palm Springs
Riveria
Beach
Royal Palm Beach

South
Bay
South
Palm Beach
Tequesta
Village
Unincorporated
Wellington
West Gate
West
Palm Beach
County
06
06
06
06
06
06
06
06
06
06
06
06
06
06
06
Volusia
City
76
75
78
96
80
82
84
86
88
90
92
00
89
93
94
Bethune
Cookman
Daytona
Beach
Daytona
Beach Airport
Daytona
Beach
De Land
De Leon Springs
Deltona
Edgewater
Holly Hill
Lake Helen
New Smyrna
Orange City
Ormond Beach
By The Sea
Pierson
Park
Bay Lake
Belle Isle
Conway
Eatonville
Edgewood
Fairview Shores
Holden
Hills
Lake Buena
Vista
Lockhart
Maitland
McCoy
AFB
Mount
Dora
Oakland
Ocoee
Ora Tran A
Orlando
Orlando
AFB
Orlando
TP
Orlovista
Pine Hills
Sky Lake
Un. Of Central
Unincorporated
Union Park
Windermere
Winter
Beach
Oak Hill
Orange
Winter
Shores
De Bary
Ormond
Apoka
Azalea
Col.
Garden
Park
Florida
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
07
30
44
31
32
47
34
35
36
49
53
51
40
56
39
41
42
33
46
58
57
43
48
45
55
00
70
50
52
54
Ponce
Inlet
Port Orange
Seville
South
Daytona
South
Peninsula
Stetson
Un.
Unincorporated
County
08
08
08
08
08
08
08
08
08
08
08
08
08
08
08
08
08
08
08
08
08
08
08
08
62
30
33
32
34
36
39
37
38
40
42
44
46
48
50
41
52
54
56
58
60
61
64
00
Escambia
09
09
09
09
09
09
09
09
09
09
09
09
09
28
30
32
66
68
72
40
50
70
00
64
62
63
Broadview
10
Browardale
10
37
29
39
28
35
Brent
Cantoment
Century
Corry Field NAS
Ellyson
Field NAS
Escambia
Myrtle
NAS
Grove
Pensacola
Saufley
Field NAS
Unincorporated
Un. Of West Florida
Warrington
West Pensacola
Broward
Carver
Coconut
Collier
A-3
Ranch
Estates
Creek
Manr/Crestha
10
10
10
County
and City / Place

Codes
Braward
(Cant.)
County
10
Cooper City
Coral Springs
Dania
Beach
Davie
Deerfield
Beach
Alachua
City
30
10
31
10
32
10
34
10
36
Sante
(Cant.)
Fe Community
University
College
Of Florida
Unincorporated
Waldo
County
11
50
11
00
11
60
28
30
32
34
36
38
40
42
50
52
53
54
60
62
00
Ft. Lauderdale
10
38
Lake
10
41
Astula
12
Hallendale
10
40
Clermont
12
Eustis
12
Beach
Hollywood
Hollywood
Ridge Farm
Lake Forest
10
42
10
44
Fruitland
10
46
Groveland
12
10
47
Howey-in-the-Hills
lady lake
12
12
Lauderdale
by the Sea
10
48
Lauderdale
Lakes
10
50
Park
12
12
Lauderhill
10
52
leesburg
Mascotte
Lazy Lake Village
10
54
Minneola
12
Lighthouse
10
56
Montverde
12
10
60
Mount
12
10
61
Tavares
12
10
62
Umatilla
12
10
67
Unincorporated
12
North Lauderdale
10
63
Oakland
10
64
Leon
10
71
Florida
A & M University
13
State University
13
Margate
Melrose
Point
Park
Miramar
North Andrews
Garden
Park
Parkland
12
Dora
31
11
Hacienda
Hillsboro
City
Pembroke
Park
10
66
Florida
Pembroke
Pines
10
68
Tallahassee
13
10
70
Unincorporated
13
30
40
50
00
10
72
10
65
Marion
10
69
Bellview
10
74
Dunnellon
14
14
14
14
14
14
14
14
30
32
34
40
42
50
00
39
15
30
48
32
34
35
36
38
44
40
Plantation
Pompano
Beach
Pompano
Beach
Hinds
Riverland
Sea Ranch
Seminole
Lakes
Indian
Res.
10
75
Mclntosh
Sunrise
10
76
Ocala
Tamarac
10
77
Reddick
Unincorporated
West Hollywood
10
00
Silver Springs
10
78
Weston
10
79
Unincorporated
West End
10
80
Wilton
Manors
Shore
Manatee
Alachua
Anna
Alachua
11
Archer
11
Gainesville
11
Hawthorne
11
High Springs
La crosse
11
Micanopy
11
Newberry
11
11
30
32
34
36
38
39
40
42
Maria
Bayshore
Gardens
15
Bradenton
Bradenton
Cedar
Hmmck/Brad
Holmes
Longboat
Memphis
Oneco
A-4
15
Beach
15
S
15
Beach
15
Key
15
15
15
County
and City / Place

Codes
Manatee
(Cant.)
Palmetto
15
City
42
County
Lee (Cont.)
County
18
Unincorporated
Parrish
15
43
Samoset
15
46
Unincorporated
15
00
Canova
West
15
50
Cape Canaveral
19
Cocoa
19
Bradenton
Brevard
Sarasota
Englewood
Gulf Gate Estates
16
Kensington
16
16
Park
16
Longboat Key
Nokomis/Laurel
16
North Port
16
Port Charlotte
16
Ridgewood
Sarasota
16
Heights
16
Sarasota
16
Sarasota
SE
16
Sarasota
Springs
16
Sarasota-Manatee
Siesta
Air
Key
16
16
Unincorporated
Venice
16
Venice
16
16
South
47
38
39
40
41
48
42
52
50
43
49
44
51
45
0
60
46
Beach
Cocoa
Beach
19
Cocoa
West
19
Eau Gallie
19
Florida
19
Inst. Of Tec
Indian
19
Harbour
Springs
17
17
17
Longwood
Oviedo
17
Sanford
17
Unincorporated
Winter Springs
17
June Park
Kennedy
Space
Center
17
17
19
Melbourne
19
Melbourne
Beach
19
Melbourne
Village
19
Merritt
Island
19
Mims
19
Palm Bay
19
Palm Shores
19
Patrick
19
AFB
South
Patrick
19
Springs
18
18
Fort Myers
18
Fort Myers
Beach
18
Fort Myers
SE
18
Fort Myers
SW
18
Vil/Pin
Lee Co. Airport
Mn
Poli
18
18
Lehigh Acres
18
North Fort Myers
18
Sanibel
18
Tice
18
19
Shores
19
Unincorporated
West Eau Gallie
19
West Melbourne
19
FL School
19
c QUIlty
StJohns
30
41
40
42
43
46
44
56
45
47
50
55
19
Titusville
for Deaf/Blind
Fla. Memorial
Cape Coral
19
19
Melbourne
30
32
38
40
44
60
00
70
19
19
Malabar
Lee
Ft. Myers
Beach
Rockledge
Satellite Beach
Casselberry
Lake Mary
Bonita
19
Indialantic
Seminole
Altamonte
City
00
College
2C I
28
30
32
34
49
36
56
38
40
47
64
60
42
66
44
65
45
41
46
62
48
50
52
51
54
00
53
43
City
51
2C I
30
Hastins
2C I
40
Marineland
2C I
42
Ponte Vedra
2C I
46
St. Augustine
2C I
50
2C I
52
2C I
00
Chattahoochee
21
Greensboro
21
Gretna
21
Havana
21
Midway
21
30
32
34
40
45
St. Augustine
Unincorporated
Beach
Gadsden
A-!;
County
and City / Place

Codes
Gadsden
(Cant.:
Highlands
County
City
21
50
Avon
Park
County
27
City
Quincy
Unincorporated
21
00
Lake
Placid
27
40
27
50
27
51
27
00
28
28
28
28
28
28
28
28
28
28
28
28
26
28
30
34
32
35
40
50
60
62
00
70
29
29
29
29
50
51
00
49
30
30
30
30
40
00
60
80
Branford
31
Live
31
31
30
40
00
32
32
32
32
32
32
32
32
32
36
38
40
42
50
00
52
54
60
Sebring
Putnam
Sebring
Crescent
City
Interlachen
Palatka
Unincorporated
Welaka
22
22
22
22
22
30
35
40
00
60
Airport
Unincorporated
Pasco
Beacon
Square
Buena Vista
Dade City
East Richey
Bay
Bayview
Calloway
Cedar Grove
Highland
Park
Lynn Haven
Mexico
Beach
Panama
City
Panama
City Beach
Parker
Springfield
Tyndall AFB
Unincorporated
23
23
23
23
23
23
23
23
23
23
23
23
28
30
32
31
34
40
50
62
51
52
60
00
Jasmine
Lakes
Estates
Land 0' Lakes

New Port Richey
Port Richey
San Antonio
St. Leo
Unincorporated
Zephyrhills
Columbia
Fort
White
Lake
City
Unincorporated
5t Lucie
Watertown
Fort Pierce
Fort Pierce
NW
Port St. Lucie

St. Lucie Village
Unincorporated
24
24
24
24
24
30
40
30
50
52
00
Hardee
Bowling
Green
Unincorporated
Wauchula
Zolfo
Springs
Jackson
Alford
Bascom
Cottondale
Graceville
Grand
Ridge
Malone
Marianna
Sneads
Unincorporated
25
25
25
25
25
25
25
25
25
28
52
30
40
42
46
50
51
00
Suwannee
Oak
Unincorporated
Indian
River
Fellsmere
Gifford
Indian
River Shores
Orchid
Osceola
Kissimmee
St. Cloud
Unincorporated
Sebastian
26
26
26
40
50
00
Unincorporated
Vero Beach
Vero Beach
Wabasso
A-R
South
County
and City / Place

Codes
Santa
Rosa
Eglin
AFB
Gulf
Breeze
County
33
City
54
Levy
Bronson
33
40
Cedar
Jay
33
42
Chiefland
Milton
33
50
Dept. of Agriculture
Unincorporated
33
00
Fanning
Whiting
33
52
Inglis
Otter Creek
Field
De Soto
Arcadia
Unincorporated
34
34
Key
Springs
Unincorporated
Williston
30
00
Yankeetown
Madison
County
39
39
39
39
39
39
39
39
39
39
City
30
40
40
40
30
40
00
41
32
34
31
42
40
41
0
60
62
Hernando
35
35
35
35
Greenville
Lee
Madison
Unincorporated
30
32
40
00
Brooksville
Weekiwachee
Unincorporated
Nassau
Walton
Defuniak
Springs
Destin
Eglin AFB
Florala
Freeport
Paxton
Port Washington
Santa
Hilliard
41
Unincorporated
41
Yulee
41
30
40
42
00
60
42
42
42
42
42
42
42
42
42
42
42
42
39
40
41
42
50
52
53
54
56
60
62
00
43
43
43
43
43
43
43
43
43
43
28
30
34
62
32
44
40
42
36
33
Callahan
Rosa Beach
Unincorporated
36
36
36
36
36
36
36
36
36
40
55
50
54
52
60
62
42
00
Fernandina
Martin
Hobe Sound
Indiantown
Taylor
37
37
37
Perry
Steinhatchee
Unincorporated
41
Beach
50
40
00
Jensen
Beach
Jupiter
Island
Ocean
Breeze
Ocean
Ridge Park
Park
Palm City
Port Salerno
Port St. Lucie
Sewalls
Monroe
Boca Chica
Boca Chica
NAS
Islamorada
Key Colony
Beach
Key Largo
Key West
Lay ton
Marathon
Munson
Island
Plantation
Tavernier
Unincorporated
38
38
38
38
38
38
38
38
38
38
38
38
48
50
30
40
41
42
44
45
46
43
52
00
Point
Stuart
Unincorporated
Okaloosa
Cinco
Bayou
Crestview
Eglin
Eglin AFB
Ft. Walton
Laurel
Beach
Hill
Mary Esther
Niceville
Ocean
City
Okaloosa
A-7
County
Airport
County
and City / Place

Codes
Okalaasa
(Cant.)
County
Washington (Cont.)
Unincorporated
Wausua
City
Shalimar
43
Unincorporated
43
00
Valparaiso
43
60
46
50
City
00
50
60
51
County
Holmes
Sumter
Unincorporated
51
Westville
51
30
32
40
00
36
52
52
52
50
60
00
53
53
53
53
52
54
50
00
54
54
54
54
40
45
50
00
55
55
55
55
44
46
50
00
56
56
56
56
40
42
00
60
57
57
50
00
58
58
58
30
32
00
Bonifay
44
44
44
44
44
44
Bushnell
Center
Hill
Coleman
Webster
Wildwood
Unincorporated
30
32
34
60
62
00
51
Eto
Ponce
De Leon
Baker
Glen
Bradford
St. Mary
Macclenny
45
45
45
45
45
Brooker
Hampton
Lawtey
Starke
Unincorporated
35
37
39
40
0
Unincorporated
Charlotte
Englewood
Port
Charlotte
Punta
Gorda
Unincorporated
Jefferson
46
46
Monticello
Unincorporated
40
00
Dixie
Citrus
Crystal
River
Homosassa
Springs
Inverness
Unincorporated
47
47
47
47
40
41
42
0
Cross
City
Cross
City AF Station
Horseshoe
Beach
Unincorporated
Gilchrist
Bell
Clay
Doctors
Green
Fanning
Inlet
Cove Springs
Keystone Heights
Lee Field NAS
Middleburg
Orange Park
Penny
Farms
Unincorporated
48
48
48
48
48
48
48
48
38
40
42
46
48
44
47
00
49
49
49
40
50
00
La
Belle
Unincorporated
Springs
Trenton
Unincorporated
Hamilton
Jasper
Jennings
Unincorporated
White
Hendry
Clewiston
51
Springs
Okeechobee
Okeechobee
Unincorporated
Calhoun
Altha
Washington
Caryville
Ebro
Vernon
50
50
50
30
40
50
Blountstown
Unincorporated
A-R
County
and City / Place

Codes
Franklin
County
County
City
Liberty
Apalachicola
59
30
Bristol
67
Eastpoint
59
31
Unincorporated
67
Carrabelle
59
32
Unincorporated
59
68
Unicorporated
Unincorporated
60
60
Flagler
Beverly
61
Haven
Beach
Bunnell
Flagler
61
Beach
61
Marineland
61
Painter
61
Hill
Unincorporated
61
40
n
28
30
40
42
44
0
Lafayette
Mayo
Unincorporated
62
62
40
0
Union
Lake
Butler
Raiford
Unincorporated
Worthing
Springs
63
63
63
63
40
41
0
50
64
64
64
64
64
64
56
40
50
52
54
0
65
65
65
65
65
30
60
62
0
64
66
66
66
66
40
0
50
52
Collier
East Naples
Everglades
I mmokalee
Naples
North Naples
Unincorporated
Wakulla
Crawfordville
Sopchoppy
St. Marks
Unincorporated
Wakulla
Gulf
Port
St. Joe
Unincorporated
Ward
Ridge
Wewahitchka
30
Unknown
Glades
Moore
City
A-9
Appendix
State
Codes
Alabama
AL
Missouri
Alaska
AK
Montana
Arizona
AZ
Nebraska
California
CA
New Hampshire
Colorado
Co
New Jersey
Connecticut
CT
New Mexico
Delaware
DE
New York
District of Columbia
DC
North Carolina
Florida
FL
North Dakota
Georgia
Hawaii
GA
Ohio
HI
Oklahoma
Idaho
ID
Oregon
Illinois
IL
Indiana
IN
Pennsylvania
Rhode Island
Iowa
IA
South Carolina
Kansas
KS
South Dakota
Kentucky
Louisiana
KY
Tennessee
LA
Texas
Maine
ME
Utah
Maryland
Massachusetts
MD
Vermont
MA
Michigan
Minnesota
MI
Washington
West Virginia
MN
Wisconsin
Mississippi
MS
Wyoming
Canada
CAN
GU
Canal Zone
Guam
Puerto
R-1
Rico
MO
MT
NE
NH
NJ
NM
NY
NC
NO
OH
OK
OR
PA
RI
SC
SO
TN
TX
UT
VT
WA
WV
WI
\AN
cz
DD

Florida Traffic Crash Report Manual

Încărcat de

Informații document

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Florida Traffic Crash Report Manual

Încărcat de

Drepturi de autor:

Formate disponibile

STATE

Information About the

This form is more commonly referred to as the "rong form report.

the traffic crash

and passenger information on form HSMV-9000S (narrative/diagram)

form at the bottom of page one.

are located on the long

The remaining data fields are

DO NOT WRITE IN THIS SPACE

.g I """'OTV , "'TV ""n"

(street, road or highway)

oF (;Ueet, road or highway)

VEH.liCENSE NUMBER I STATE I VEHICLE IDENTIFICATION NUMBER

?~sted SD~ed EST. VEHICLE DAMAGE

EST TRAILERDAMAGE 'DAMAGE L

VEHICLE REMOVED BY:

CURRENT ADDRESS (Number and Street)

CITY AND STATE

ALCOHOL I DRUG USE

I SAFETY EQUIPMENT IN USE

HSMV.90003 (REV. 01/02)

NUMBER FROM DIAMOND OR BOX

CITY STATE&2IP CODE

and Location Information

the day by using the numbers

day, and year order in the following

by using the numbers

Enter the time of day or the approximate

time of day the traffic crash occurred.

mark in the AM or PM box

Use the 12 hour clock system

the time of the crash.

Do not use the 24 hour clock system

Enter the time of day you were notified

the time you were notified

Do not use the 24

> Place an X or a check

Enter the time of day you arrived

mark in the AM or PM box.

Use the 12 hour clock system

of the traffic crash.

at the scene of the traffic crash.

mark in the AM or PM box.

Use the 12 hour clock system

use the 24 hour clock system

the time you arrived

Time and Location Information

> Enter the report or file number

report or file number.

report or file number

report or file number

and Location Information

CITY OR TOWN (Continued)

> Enter the complete

> Enter the node number(s)

side of the crash scene,

has not been assigned,

enter the node number

and enter it in the space titled "Next

and enter the

Node No.", and enter the distance

the next closest

Node No." space

in the space titled "From