Car_Inspection_Form_issue_5_May2014

CAR INSPECTION FORM

CASE NUMBER:__________________
ELEMENT NUMBER:____________________
Administration
Inspection completed 0 = No; 1 = Yes

Inspection date yyyymmdd

Inspection duration
Start Time: hh.mm

End Time: hh.mm

Duration: Minutes
2 = Driver; 3 = Passenger;
Source of information locating 4 = Owner if not occupant;
vehicle 5 = Police; 6 = Towing service;
7 = Workshop/auto wrecker

Distance to inspection site km

Mandatory safety Inspection
0 = No; 1 = Yes
done? (Newer car than 3-year not inspected yet = 1 yes)

Date of the safety inspection or if

newer car not inspected yet date (month, year)
of manufacture.

Investigators (name)

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

General (1)
Vehicle Identification
Registration Number
VIN Number
Country of Registration
Accident participant according to
A; B; C
DaCoTA accident type
Traveled Lane
Conditions and Defects
General Conditions (body,
2 = Excellent; 3 = Good; 4 = Average; 5 = Bad
outside)
Condition of seat 2 = Good - Normal; 3 = Defective

Defect in vehicle that may have

contributed to the accident
Defect in braking components
Defect in suspension and shock
0 = No; 2 = Yes (specify in comment)
absorption
Defect in steering components
Defect in lights and turn signals
Other defects in vehicle
Make and Model
Make
Model

Year and month of manufacture

Model Year
Colour according reg.
1 = 1 Star; 2 = 2 Stars; 3 = 3 Stars; 4 = 4 Stars;
Euro NCAP rating 5 = 5 Stars; 6 = Not Rated
0 = No; 3 = Taxi; 4 = Police; 5 = Fire Brigade;
Special use car 6 = Ambulance; 7 = Military; 8 = Learner's Car;
9 = Rental Car
Number of side doors
2 = Sedan; 3 = Hatchback/Wagon; 4 = Sports;
5 = Convertible; 6 = Derivative;
Body style 7 = Off-road/SUV; 8 = MPV/Minibus;
9 = Pick-up; 10 = Van

(If convertible)
Soft/hard top 2 = Hard; 3 = Soft; 4 = Retractable hardtop; 5 = No roof
Soft/hard top up/down 2 = Up; 3 = Down

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Vehicle Geometry and Weight

Engine power kW
Hybrid vehicle 0 = No; 1 = Yes
2 = Manual; 3 = Automatic;
Gearbox type 4 = Automatic with manual shift mode

2 = Petrol and Ethanol;

Fuel type
3 = Diesel/RME;
4 = Electricity;
Alternative Fuel 5 = Natural/bio gas

Driven wheels 2 = Front; 3 = Rear; 4 = Four wheel drive

Drive of vehicle 2 = Left; 3 = Right

Vehicle length mm
Vehicle width mm

Axle distance mm
Kerb weight kg

General (2)
Cargo
0 = No; 3 = 0-25 kg; 4 = 26-50 kg; 5 = 51-100 kg;
Cargo in passenger compartment 6 = More than 100 kg; 7 = Yes, unknown weight
Anchored 0 = No; 1 = Yes
0 = No; 3 = 0-25 kg; 4 = 26-50 kg; 5 = 51-100 kg;
Cargo in luggage compartment 6 = More than 100 kg; 7 = Yes, unknown weight
Anchored 0 = No; 1 = Yes
0 = No; 3 = 0-25 kg; 4 = 26-50 kg; 5 = 51-100 kg;
Cargo on roof 6 = More than 100 kg; 7 = Yes, unknown weight

Modifications
Modifications 0 = No; 1 = Yes

If yes, specify modifications:

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Impacts
General

CDC 1,2

CDC 3

CDC 4, 4e

CDC 5

CDC 7

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Impact
(First Impact)
Frontal Deformation
Rear Deformation
Side Deformation - Left (Mark all that apply)
Side Deformation - Right
Top
CDC
CDC 1,2 00-12
F = Front; R = Right; B = Back; L = Left;
CDC 3 T = Top; U = Undercarraige; X = Unclassifiable
L = Left Third; C = Centre Third; R = Right Third;
Y = Left 2/3; Z = Right 2/3; D = Full Width
F = Front Compartment P = Passenger Compartment
CDC 4 B = Back Compartment Y = Front and Passenger Compartment
Z = Passenger and Back Compartment
D = Full Length
CDC4e 0-2
L = Long. rail height incl. undercarriage;
M = Above rail/frame to belt line or hood;
G = Above belt line or hood;
H = Above rail/frame;
CDC5 E = Below belt line or hood;
A = Full height;
W = Below undercarriage / wheels + tires only;
L = Left third; C = Centre third; R = Right third;
Y = Left 2/3; Z = Right 2/3; D = Full width
W = Wide impact area
N = Narrow impact area
S= Sideswipe; O = Rollover / roll onto side
CDC6 A = Overhanging structures
E = Corner, less than 410 mm
K = Conversion in impact type
U = No residual deformation
CDC7 1-9

Deformation Measurements
C1 deformation mm
C2 deformation mm Measured at bumper/sill height if damaged.
C3 deformation mm Otherwise note where and how measured.
C4 deformation mm
C5 deformation mm
C6 deformation mm C1 to C6 = from left to right or from rear to front
Maximum Deformation mm
Length of Deformation mm
Deformation distance from vehicle
front mm Measured to cc of damage
Deformation distance from CoG
mm Measured from COG to cc of deformation

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Impact
(Second Impact)
Frontal Deformation
Rear Deformation
Side Deformation - Left (Mark all that apply)
Side Deformation - Right
Top
CDC
CDC 1,2 00-12
F = Front; R = Right; B = Back; L = Left;
CDC 3 T = Top; U = Undercarraige; X = Unclassifiable
L = Left Third; C = Centre Third; R = Right Third;
Y = Left 2/3; Z = Right 2/3; D = Full Width
F = Front Compartment P = Passenger Compartment
CDC 4 B = Back Compartment Y = Front and Passenger Compartment
Z = Passenger and Back Compartment
D = Full Length
CDC4e 0-2
L = Long. rail height incl. undercarriage;
M = Above rail/frame to belt line or hood;
G = Above belt line or hood;
H = Above rail/frame;
CDC5 E = Below belt line or hood;
A = Full height;
W = Below undercarriage / wheels + tires only;
L = Left third; C = Centre third; R = Right third;
Y = Left 2/3; Z = Right 2/3; D = Full width
W = Wide impact area
N = Narrow impact area
S= Sideswipe; O = Rollover / roll onto side
CDC6 A = Overhanging structures
E = Corner, less than 410 mm
K = Conversion in impact type
U = No residual deformation
CDC7 1-9

Deformation Measurements
C1 deformation mm
C2 deformation mm Measured at bumper/sill height if damaged.
C3 deformation mm Otherwise note where and how measured.
C4 deformation mm
C5 deformation mm
C6 deformation mm C1 to C6 = from left to right or from rear to front
Maximum Deformation mm
Length of Deformation mm
Deformation distance from vehicle
front mm Measured to cc of damage
Deformation distance from CoG
mm Measured from COG to cc of deformation

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Impact
(Third Impact)
Frontal Deformation
Rear Deformation
Side Deformation - Left (Mark all that apply)
Side Deformation - Right
Top
CDC
CDC 1,2 00-12
F = Front; R = Right; B = Back; L = Left;
CDC 3 T = Top; U = Undercarraige; X = Unclassifiable
L = Left Third; C = Centre Third; R = Right Third;
Y = Left 2/3; Z = Right 2/3; D = Full Width
F = Front Compartment P = Passenger Compartment
CDC 4 B = Back Compartment Y = Front and Passenger Compartment
Z = Passenger and Back Compartment
D = Full Length
CDC4e 0-2
L = Long. rail height incl. undercarriage;
M = Above rail/frame to belt line or hood;
G = Above belt line or hood;
H = Above rail/frame;
CDC5 E = Below belt line or hood;
A = Full height;
W = Below undercarriage / wheels + tires only;
L = Left third; C = Centre third; R = Right third;
Y = Left 2/3; Z = Right 2/3; D = Full width
W = Wide impact area
N = Narrow impact area
S= Sideswipe; O = Rollover / roll onto side
CDC6 A = Overhanging structures
E = Corner, less than 410 mm
K = Conversion in impact type
U = No residual deformation
CDC7 1-9

Deformation Measurements
C1 deformation mm
C2 deformation mm Measured at bumper/sill height if damaged.
C3 deformation mm Otherwise note where and how measured.
C4 deformation mm
C5 deformation mm
C6 deformation mm C1 to C6 = from left to right or from rear to front
Maximum Deformation mm
Length of Deformation mm
Deformation distance from vehicle
front mm Measured to cc of damage
Deformation distance from CoG
mm Measured from COG to cc of deformation

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Front Impact
Left side. Right side
1 2 3 1 2 3

Front Wheel Into Sill * See below

2 = None; 3 = Minor (0-2 cm);

4 = Small (3-10 cm);
Upper Longitudinal Deformation 5 = Moderate (11-20 cm);
6 = Major (>20 cm)
2 = No deformation force;
Upper Longitudinal Hit 3 = Direct hit; 4 = Indirect force
2 = Not deformed; 3 = Bending;
Upper Deformation mode 4 = Crumpling; 5 = Both

2 = None; 3 = Minor (0-2 cm);

4 = Small (3-10 cm);
Front Longitudinal Deformation 5 = Moderate (11-30 cm);
6 = Major (>30 cm)
2 = No deformation force;
Front Longitudinal Hit 3 = Direct hit; 4 = Indirect force
2 = Not deformed; 3 = Bending;
Front Deformation mode 4 = Crumpling; 5 = Both

Impact No.
1 2 3
2 = None
Roof 3 = Minor deformation
Front edge longitudinal deformation 4 = Moderate deformation (<20 cm)
5 = Major deformation (>20 cm)
2 = None
A-pillar Damage Left side 3 = Minor deformation
4 = Moderate deformation (up to 10 cm)
A-pillar Damage Right side 5 = Major deformation (more than 10cm)
6 = Rupture
2 = None; 3 = Minor (0-2cm) ;
Powertrain 4 = Moderate (3cm-dash-panel contact);
Dislocation 5 = Major (major dash panel dislocation due
to engine dislocation)
2 = No deformation force; 3 = Direct hit;
Hit 4 = Indirect force

* Wheel Into Sill

2 = None
3 = Minor (wheel dislocated 0-2 cm)
4 = Small (wheel dislocated 3 cm-sill contact)
5 = Moderate (sill deformed longitudinally up to 10 cm due to wheel dislocation)
6 = Major (sill deformed longitudinally more than 10 cm due to wheel dislocation)

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Rear Impact

Rear Impact
Left Right

1 2 3 1 2 3

Rear Wheel Into Sill ** See below

Longitudinal

Rear Longitudinal Deformation * See below

2 = No deformation force;
Rear Longitudinal Hit 3 = Direct hit; 4 = Indirect force
2 = Not deformed; 3 = Bending;
Rear Deformation Mode 4 = Crumpling; 5 = Both

Impact No.
1 2 3

Rear Axle Longitudinal Dislocation * See below

* Longitudinal Deformation ** Wheel Into Sill

2 = None 2 = None
3 = Minor deformation (0-2 cm) 3 = Minor (wheel dislocated 0-2 cm)
4 = Small (3-10 cm) 4 = Small (wheel dislocated 3 cm-sill contact)
5 = Moderate (11-30 cm) 5 = Moderate (sill deformed longitudinally up to 10 cm due to wheel dislocation)
6 = Major (>30 cm) 6 = Major (sill deformed longitudinally more than 10 cm due to wheel dislocation)

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Top
Pillar deformation Left Right
A-pillar
B-pillar
C-pillar
D-pillar

Roof deformations at position;

Seat Position Row 1, Left 2 = None
Seat Position Row 1, Middle 3 = Minor (0-2 cm)
4 = Moderate (3-10 cm)
Seat Position Row 1, Right
5 = Major (> 10 cm)
Seat Position Row 2, Left
Seat Position Row 2, Middle
Seat Position Row 2, Right
Seat Position Row 3, Left
Seat Position Row 3, Middle
Seat Position Row 3, Right

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Side Impacts
Left Side Deformations

Second row measurements Only

are to be measured at
approx. 5cm below window
measured if
line third row of
seating
exist

1 2 3 4 5 6 7

Measured at height of side roof rail 1

Measured at approx. 5cm below 2 = None
2
window line 3 = Minor (0-5 cm)
Measured at height of mid doornot 4 = Moderate (6-20 cm)
3 5 = Major (More than 20 cm)
incl. Window
Measured at sill height 4

Right Side Deformations

Only
measured if
third row of
seating exist

7 6 5 4 3 2 1

Measured at height of side roof rail 1

Measured at approx. 5cm below 2 = None
2
window line 3 = Minor (0-5 cm)
Measured at height of mid doornot 4 = Moderate (6-20 cm)
3 5 = Major (More than 20 cm)
incl. Window
Measured at sill height 4

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Pedestrian
Pedestrian Contacts
Pedestrian contact No: 1 2 3 4 5 6 7
X-Distance
cm

Y-distance
cm

Z-Distance
cm

Wraparound-distance
cm

Vehicle area
* See below

Body Region
** See below

* Vehicle Area ** Body Region

2 = Bumper left 2 = Lower leg
3 = Bumper centre 3 = Knee
4 = Bumper right 4 = Upper leg
5 = Bonnet leading edge left 5 = Pelvis
6 = Bonnet leading edge centre 6 = Abdomen
7 = Bonnet leading edge right 7 = Thorax
8 = Front hood left 8 = Shoulder
9 = Front hood centre 9 = Upper arm
10 = Front hood right 10 = Elbow
11 = Rear hood left 11 = Lower arm
12 = Rear hood centre 12 = Head
13 = Rear hood right
14 = A-pillar left
15 = A-pillar right
16 = Fender left
17 = Fender right
18 = Windscreen left
19 = Windscreen centre
20 = Windscreen right
21 = Upper windscreen frame
22 = Roof

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Exterior
General
General
Towing hook presence 2 = No towing hook; 3 = No hook present; 4 = Hook present
Towing hook condition 2 = Intact; 3 = Damaged

Hood openable 2 = Openable

3 = Unopenable
Boot lid openable 4 = Opened in crash

Engine orientation 2 = Transverse; 3 = Longitudinal

Engine placing 2 = Front; 3 = Rear or Middle

Battery placing, electric engine 2 = Front; 3 = Over front axle; 4 = Middle; 5 = Over rear axle; 6 = Rear

Fire 0 = No; 1 = Yes

2 = Engine and engine compartment;
Fire start location 3 = Occupant compartment (including dashpanel);
4 = Luggage compartment; 5 = Under vehicle; 6 = Outside source

Marks from extrication, tow-away 0 = No; 1 = Yes

Fuel and Batteries

0 = No
3 = Minor damage
Battery damage
4 = Moderate visible damage
5 = Major damage
2 = Attached
Battery attatchment 3 = Loose

Fueltank 2 = Intact
Fuelfiller pipes and caps 3 = Damaged without holes
Fuel pipes 4 = Damaged with hole

Leakage
Liquid fuel Windscreen washer fluid
Gas fuel Cooling lquid
Engine oil Acid 0 = No; 1 = Yes
Gearbox oil Brake fluid
Power steering oil
Compatibility Geometry

Front bumper beam height (mm)

Front longitudinal height (mm)

Compatibility protection 0 = No; 1 = Yes

Compatibility protection height (mm)

Rear bumper beam height (mm)

Sill height (mm)

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Doors and Glazing

Doors
Left Right
2 = Openable; 3 = Openable only from outside;
Front door function
4 = Openable only from inside; 5 = Unopenable;
6 = Door opened in crash;
Rear door function 7 = door opened by rescue services using tools

Longitudinal Deformation
Left Right
Frontal door opening longitudinal
Deformations measured at waistline!
deformation
2 = None
Frontal sill longitudinal deformation
3 = Minor (0-2 cm)
Rear door opening longitudinal 4 = Moderate (3-10 cm)
deformation 5 = Major (> 10 cm)

Rear sill longitudinal deformation

Side Windows
Side Window Damage Left Right
Front Row 0 = No; 3 = Yes, broken not holed;
Second Row 4 = Yes, holed and/or partly separated/opened;
Third Row 5 = Yes, completely crushed/separated or opened window

Side Window Laminated Left Right

Front Row
Second Row 0 = No; 1 = Yes
Third Row
Other Glazing
Sunroof 2 = No sunroof; 3 = Hatch (openable); 4 = Glass roof (not openable)
0 = No; 4 = Opened sunroof; 6 = Yes, broken not holed if glass
Sunroof damaged 7 = Yes, completely crushed/separated
8 = Yes, holed and/or partly separated and/or partly opened

0 = No
Windscreen damaged
3 = Yes, broken not holed
4 = Yes, holed and/or partly separated
Rear window damaged
5 = Yes, completely crushed/separated window

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Wheels
Axles
Left Right
Axle distance differrence [mm]

Front wheels

Tyre make Left

front
Tyre model wheel

Tyre make Right

front
Tyre model wheel

Left front wheel Right front wheel

2 = Steel; 3 = Alloy;
Rim type 4 = Small size spare wheel
2 = Undamaged; 3 = Minor damage
Rim condition 4 = Major damage

2 = Summer; 3 = Winter studded;

Tyre type 4 = Winter not studded;
5 = All Season; 6 = Mud and Terrain
Recapped tire 0 = No; 1 = Yes

Tyre width mm
175/70 R13 82T

Aspect ratio
Rim diameter inch

Load index 0-279

Tyre speed rating

Manufacturing date wwyy

Depth of tyre mm

Tyre pressure Value in kg/cm2

0 = No; 2 = Yes, pre-crash
Tyre blown out 3 = Yes, in crash; 4 = Yes, post-crash
5 = Yes, unknown when
0 = No; 2 = Yes, partly separated
Wheel separated from vehicle 3 = Yes, completely separated
Tyre and wheel defect having
*See below
played a role in the accident.
*Tyre defect type
0 = No, 3 = blow-out; 4 = difference in types 5 = difference in dimension; 6 = wear (tread >1,6mm); 7 = uneven wear;
8 = play in bearings (wheel axle) 9 = tyre dimensions not i conformance
10 = pressures (difference > up to 0.3 bar between wheels on the same axle or from builder's specifications)

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Wheels
Rear wheels

Tyre make Left

rear
Tyre model wheel

Tyre make Right

rear
Tyre model wheel

Left rear wheel Right rear wheel

2 = Steel; 3 = Alloy;
Rim type 4 = Small size spare wheel
2 = Undamaged; 3 = Minor damage
Rim condition 4 = Major damage

2 = Summer; 3 = Winter studded;

Tyre type 4 = Winter not studded;
5 = All Season; 6 = Mud and Terrain
Recapped tire 0 = No; 1 = Yes

Tyre width mm
175/70 R13 82T

Aspect ratio
Rim diameter inch

Load index 0-279

Tyre speed rating

Manufacturing date wwyy

Depth of tyre mm

Tyre pressure Value in kg/cm2

0 = No; 2 = Yes, pre-crash
Tyre blown out 3 = Yes, in crash; 4 = Yes, post-crash
5 = Yes, unknown when
0 = No; 2 = Yes, partly separated
Wheel separated from vehicle 3 = Yes, completely separated
Tyre and wheel defect having
*See below
played a role in the accident.
*Tyre defect type
0 = No, 3 = blow-out; 4 = difference in types 5 = difference in dimension; 6 = wear (tread >1,6mm); 7 = uneven wear;
8 = play in bearings (wheel axle) 9 = tyre dimensions not i conformance
10 = pressures (difference > up to 0.3 bar between wheels on the same axle or from builder's specifications)

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Trailer
Trailer
Towing Vehicle 0 = No; 1 = Yes
Trailer kerb weight kg
Trailer gross weight kg
Trailer cargo weight kg
Trailer center of gravity 2 = Center; 3 = Far front; 4 = Far rear
Trailer vertical center of gravity 2 = High; 3 = Low; 4 = Medium

Trailer overload
0 = No; 1 = Yes
Identified mechanical failure in trailer

Trailer details:

Interior
General
Steering wheel out of position 0 = No; 1 = Yes
0 = No; 3 = Yes, deformed by occupant
Steering wheel deformation 4 = Yes, deformed by other
5 = Yes, unknown cause

Longitudinal deformation
Left side dashpanel intrusion 2 = None or minor deformation (0-5 cm)
Right side dashpanel intrusion 3 = Moderate (6-15 cm); 4 = Major (>15 cm)
Left frontal footwell 2 = None; 3 = Minor 0-5 cm;
Right frontal footwell 4 = Moderate (6-15 cm); 5 = Major (>15 cm)

Inner accessories/Infotainment 0 = No; 1 = Yes

Cargo net 2 = No net in use; 3 = Yes, in use

Infotainment details:

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Belt and Seat

Seat Information
Seat position 1.1 1.2 1.3
Seating direction 2 = Forward facing; 3 = Rearward facing; 4 = Lateral
Longitudinal seat position 2 = Front; 3 = Middle; 4 = Rear
Seat separated from floor 0 = No; 1 = Yes

2 = Fabric; 3 = Leather; 4 = Synthetic leather-like;

Seat covers 5 = Both leather and fabric
Additional seat covers 0 = No; 1 = Yes

0 = No; 3 = Yes, longitudinal and backrest

Electric adjustment system 4 = Yes, longitudinal only; 5 = Yes, backrest only
6 = Yes, unknown type
Backrest position 2 = Upright; 3 = Middle; 4 = Leaning back

2 = Not deformed; 3 = Deformed by occupant;

4 = Deformed by other occupant; 5 = Deformed by
Backrest deformation cargo; 6 = Deformed by vehicle structure;
7 = Deformed by unknown object
Neck restraint 0 = No; 3 = Yes, adjustable; 4 = Yes, fixed
Neck restraint position (if adjustable) 2 = Lower; 3 = Middle; 4 = Upper
Whiplash protection 0 = No; 1 = Yes
Whips measurement mm

Belt Information
1.1 1.2 1.3
Seat belt code
2 = No sign; 3 = Signs indicating use of seat belt;
Signs of seat belt usage 4 = Signs indicating no use of seat belt

Upper belt attachment 2 = Pillar; 3 = Seatback; 4 = Cross-car beam; 5 = Roof

Belt malfunction 0 = No; 1 = Yes
2 = Fixed; 3 = Automatically adjustible;
Upper attachment type 4 = Manually adjustible

Friction marks, webbing 0 = No; 1 = Yes

0 = No; 3 = Yes, in reel; 4 = Yes, in buckle;
Pretensioner Type 5 = Yes, in lower fixation; 6 = Yes, multiple
pretensioners; 7 = Yes, unknown location
2 = No movement; 3 = Yes, upwards; 4 = Yes,
Movement through buckle downwards; 5 = Yes, both upwards and downwards
6 = Yes, unknown direction
Pretensioner Activated 0 = No; 1 = Yes

0 = No; 3 = Yes, D-ring; 4 = Yes, buckle;

Belt Jammed 5 = Yes, both D-ring and buckle
Load limiter 0 = No; 1 = Yes
2 = No belt; 3 = Two point belt - lap;
Seat belt type 4 = Two point belt - chest; 5 = Three point belt;
6 = Four point belt; 7 = Five point belt

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Belt and Seat

Seat Information
Seat position 2.1 2.1 2.3
Seating direction 2 = Forward facing; 3 = Rearward facing; 4 = Lateral
Longitudinal seat position 2 = Front; 3 = Middle; 4 = Rear
Seat separated from floor 0 = No; 1 = Yes

2 = Fabric; 3 = Leather; 4 = Synthetic leather-like;

Seat covers 5 = Both leather and fabric
Additional seat covers 0 = No; 1 = Yes

0 = No; 3 = Yes, longitudinal and backrest

Electric adjustment system 4 = Yes, longitudinal only; 5 = Yes, backrest only
6 = Yes, unknown type
Backrest position 2 = Upright; 3 = Middle; 4 = Leaning back

2 = Not deformed; 3 = Deformed by occupant;

4 = Deformed by other occupant; 5 = Deformed by
Backrest deformation cargo; 6 = Deformed by vehicle structure;
7 = Deformed by unknown object
Neck restraint 0 = No; 3 = Yes, adjustable; 4 = Yes, fixed
Neck restraint position (if adjustable) 2 = Lower; 3 = Middle; 4 = Upper
Whiplash protection 0 = No; 1 = Yes
Whips measurement mm

Belt Information
2.1 2.2 2.3
Seat belt code
2 = No sign; 3 = Signs indicating use of seat belt;
Signs of seat belt usage 4 = Signs indicating no use of seat belt

Upper belt attachment 2 = Pillar; 3 = Seatback; 4 = Cross-car beam; 5 = Roof

Belt malfunction 0 = No; 1 = Yes
2 = Fixed; 3 = Automatically adjustible;
Upper attachment type 4 = Manually adjustible

Friction marks, webbing 0 = No; 1 = Yes

0 = No; 3 = Yes, in reel; 4 = Yes, in buckle;
Pretensioner Type 5 = Yes, in lower fixation; 6 = Yes, multiple
pretensioners; 7 = Yes, unknown location
2 = No movement; 3 = Yes, upwards; 4 = Yes,
Movement through buckle downwards; 5 = Yes, both upwards and downwards
6 = Yes, unknown direction
Pretensioner Activated 0 = No; 1 = Yes

0 = No; 3 = Yes, D-ring; 4 = Yes, buckle;

Belt Jammed 5 = Yes, both D-ring and buckle
Load limiter 0 = No; 1 = Yes
2 = No belt; 3 = Two point belt - lap;
Seat belt type 4 = Two point belt - chest; 5 = Three point belt;
6 = Four point belt; 7 = Five point belt

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Belt and Seat

Seat Information
Seat position 3.1 3.2 3.3
Seating direction 2 = Forward facing; 3 = Rearward facing; 4 = Lateral
Longitudinal seat position 2 = Front; 3 = Middle; 4 = Rear
Seat separated from floor 0 = No; 1 = Yes

2 = Fabric; 3 = Leather; 4 = Synthetic leather-like;

Seat covers 5 = Both leather and fabric
Additional seat covers 0 = No; 1 = Yes

0 = No; 3 = Yes, longitudinal and backrest

Electric adjustment system 4 = Yes, longitudinal only; 5 = Yes, backrest only
6 = Yes, unknown type
Backrest position 2 = Upright; 3 = Middle; 4 = Leaning back

2 = Not deformed; 3 = Deformed by occupant;

4 = Deformed by other occupant; 5 = Deformed by
Backrest deformation cargo; 6 = Deformed by vehicle structure;
7 = Deformed by unknown object
Neck restraint 0 = No; 3 = Yes, adjustable; 4 = Yes, fixed
Neck restraint position (if adjustable) 2 = Lower; 3 = Middle; 4 = Upper
Whiplash protection 0 = No; 1 = Yes
Whips measurement mm

Belt Information
3.1 3.2 3.3
Seat belt code
2 = No sign; 3 = Signs indicating use of seat belt;
Signs of seat belt usage 4 = Signs indicating no use of seat belt

Upper belt attachment 2 = Pillar; 3 = Seatback; 4 = Cross-car beam; 5 = Roof

Belt malfunction 0 = No; 1 = Yes
2 = Fixed; 3 = Automatically adjustible;
Upper attachment type 4 = Manually adjustible

Friction marks, webbing 0 = No; 1 = Yes

0 = No; 3 = Yes, in reel; 4 = Yes, in buckle;
Pretensioner Type 5 = Yes, in lower fixation; 6 = Yes, multiple
pretensioners; 7 = Yes, unknown location
2 = No movement; 3 = Yes, upwards; 4 = Yes,
Movement through buckle downwards; 5 = Yes, both upwards and downwards
6 = Yes, unknown direction
Pretensioner Activated 0 = No; 1 = Yes

0 = No; 3 = Yes, D-ring; 4 = Yes, buckle;

Belt Jammed 5 = Yes, both D-ring and buckle
Load limiter 0 = No; 1 = Yes
2 = No belt; 3 = Two point belt - lap;
Seat belt type 4 = Two point belt - chest; 5 = Three point belt;
6 = Four point belt; 7 = Five point belt

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Airbag
A B C D E F G H I
Airbag Row 1; 2; 3
1 = Driver side
Airbag side 2 = Middle
3 = Passenger side
Airbag type * See below

2 = Deployed
3 = Deployed but
Airbag deployment blocked
4 = Not deployed
Airbag damaged
Airbag removed
post-crash 0 = No; 1 = Yes

Airbag disconnected
No. of chambers
1; 2; 3
(if side airbag)
*Airbag Type
2 = Steering wheel 12 = Seat-back thorax
3 = Facia 13 = Seat-back head & thorax
4 = Knee 14 = Seat-back thorax & pelvis
5 = Footwell 15 = Seat-back head & thorax & pelvis
6 = Back of seat in front 16 = Seat-back NFS
7 = Door thorax 17 = Inflatable tube for this seat
8 = Door head & thorax 18 = Inflatable tube for this seat and position behind
9 = Door thorax & pelvis 19 = Inflatable curtain for this seat
10 = Door head & thorax & pelvis 20 = Inflatable curtain for this seat and position behind
11 = Door NFS 21 = Cant rail NFS
22 = Door mounted inflatable curtain (e.g. Volvo c70)

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Interior Observations

Mark observations in pictures and describe below.

"hitmarks, deformations, separations, sharp edges etc. "

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

EDR
EDR

Delta V, longitudinal Safety belt status, right front passenger

Maximum delta V, longitudintal Frontal airbag suppression switch

status, right front passenger
Time, maximum delta V Frontal airbag deployment, time to nth
stage, driver
Speed, vehicle indicated Frontal airbag deployment, time to nth
stage, right front passanger
Engine throttle, % full Side airbag deployment, time to deploy,
(or accelorator pedal, % full) driver
Service brake, on/off Side airbag deployment, time to deploy,
right front passenger
Ignition cycle, crash
Ignition cycle, download Side curtain/tube airbag deployment,
time to deploy, driver side
Safety belt status, driver Side curtain/tube airbag deployment,
time to deploy, right side
Airbag deployment time, driver Pretensioner, time to fire, driver

Airbag Deployment Time, Pretensioner, time to fire, right front

right front passenger passenger
Multi-event, number of events Seat track position switch, foremost,
(1,2) status, driver
Time from event 1 to 2 Seat track position switch, foremost,
status, right front passenger
Complete file recorded (yes, no) Occupant size classification, driver

Lateral acceleration Occupant size classification, right front

passenger
Longitudinal acceleration Occupant position classification, driver

Normal acceleration Occupant position classification, right

front passenger

Delta V, lateral Pre-crash yawing

Maximum delta V, lateral Turning indicator
Time, maximum delta V, lateral Headlights

Time, maximum delta V, resultant Clutch

Horn
Engine RPM
Vehicle roll angle
ABS activity (engaged, not
engaged)
Stability control (on, off,
engaged)
Steering input

When applicable, use below proposed codes.

—= Not applicable (7777) OT= Other (8888) U= Unknown (9999)
 Car_Inspection_Form_issue_5_May2014

Safety Systems
Support and Warning Systems

Imparment warning system

0 = No
Alcolock
2 = Yes, not in use
Lane departure warning 3 = Yes, in use
Forward collision warning 4 = Yes, unknown if in use
Rearward collision warning
Blind spot indicator
Cruise control *See below
GPS 0 = No; 1 = Yes

*Cruise Control
0 = No; 3 = Yes, non-adaptive, not in use; 4 = Yes, non-adaptive, in use;
5 = Yes, non-adaptive, unknown if in use;
6 = Yes, adaptive, not in use; 7 = Yes, adaptive, in use; 8 = Yes, adaptive, unknown if in use;
9 = Yes, stop-and-go, in use;
10 = Yes, stop-and-go, not in use; 11 = Yes, stop-and-go, unknown if in use;
12 = Yes, unknown type, in use;
13 = Yes, unknown type, not in use; 14 = Yes, unknown type, unknown if in use
Other
Active Hood 0 = No; 1 = Yes

Brake and Handling Systems

Electronic stability program 0 = No; 2 = Yes, not in use;
Traction control system 3 = Yes, in use; 4 = Yes, unknown if in use

ABS
Active brake light
0 = No; 1 = Yes
Brake assist
Automatic emergency brake
Visibility
Xenon lights 0 = No;
3 = Yes, low beam only
4 = Yes, high beam only
5 = Yes, both high and low beam
6 = Yes, not further specified

Night vision 0 = No; 3 = Yes, not in use; 4 = Yes, in use;

Active headlamps 5 = Yes, unknown if in use

When applicable, use below proposed codes.

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