Interview_Form_issue_2_June2012

INTERVIEW FORM
CASE NUMBER:_________________
Vehicle ID
Road User ID

General

How did DaCoTA get the contact information?

Date of interview yyyymmdd

Interview Summary

Accident summary according to driver

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Interview_Form_issue_2_June2012

Weather according to driver

2 = Dry; 3 = Wettish; 4 = Wet; 5 = Thin ice;

Road conditions according to driver
6 = Thick ice/packed snow; 7 = Fresh snow/slash; 8 = Hail

Dazzling lights 0 = No; 1 = Yes

0 = No; 3 = 10-15m/s; 4 = 15-20m/s;
Strong winds
5 = 20-25m/s; 6 = 25+m/s

Accident site
Traffic at accident time according to driver 2 = Low; 3 = Normal; 4 = High
Speed limit according to driver
2 = None; 3 = Yes, by vegitation;
Visibility problems
4 = Yes, by signs; 5 = Yes, other

Vehicle

Active systems

Speed at accident time according to driver

2 = Full headlights; 3 = Dipped headlights;
Lights at accident time according to driver
4 = Notice lights; 5 = Fog lights

Directional indicator 0 = No; 1 = Yes

Lights on bicycle/moped 2 = On; 3 = Off

Road user
Hearing according to driver 2 = Good; 3 = Good with aid;
Vision according to driver 4 = Slightly impaired; 5 = Poor

Type of driving license

Driving licence since yyyy

Obligation in driver licence 0 = No; 1 = Yes, describe
Distance driven per year

Total distance driven

Professional driver during lifetime? 0 = No; 1 = Yes, describe
How long has driver driven this vehicle? [In years]
Familiar with the vehicle model 0 = No; 1 = Yes
How often does driver drive this vehicle? 2 = Daily; 2 = Weekly; 3 = Monthly; 4 = Yearly

Familiarity with accident site?

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)