SCI Notification Form

Investigating Police Jurisdiction:

Contact Person:

Phone Number:

Email:

Crash Date:

Crash Location:

Specific Reason for Special Interest:

(example Passenger air bag child fatality)

Vehicle Year/Make/Model of Special Interest Vehicle:

Minor Moderate Severe / Front Side Back

Damage: (check all that apply)

No Yes (If Yes, please check where, below)

Air Bag Deployed:

Driver Side Passenger Side Left Door Right Door

If Air Bag Deployed, indicate where:

Occupant Information

Name:

Seat Position:

Phone Number:

Treatment Status:

Male Female

Sex:

Age:

Height:

Weight:

Yes No

Seat Belt Usage:

Describe Indications of Belt Usage:

Injury Information:

Comments: