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HomeMy Public PortalAboutPRR 17-2589TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered in person September 18, 2017 David Rouchard Re: GS #2589 (Police Report) Would like a copy ojthe police report #17-1704. Dear David Rouchard: The Town of Gulf Stream has received your public records request dated September 18, 2017. You should be able to view your original request and response at the following link: hgp://www2.gulf-stream.org/weblink/O/doc/112957/Paeel aspx We consider this request closed. Sincerely, K° cr As requested by Rita Taylor Town Clerk, Custodian of the Records Sworn Statement for Traffic Crash Report Information Motor Vehicle crash information Is confidential and exempt from disclosure for a period of 60 days after the crash report is filed. §316.066(2)(a) Florida Statutes (2014). Obtaining confidential Information by someone who knows they are not entitled to do so Is a felony violation. The undersigned requests the following crash report (date/locatfon/parties: The undersigned states that he/she or the organization represented qualify for immediate disclosure of the crash report according to the exemption checked below and does swear or affirm that the information contained in a crash report made confidential by statute will not be used for any commercial solicitation of accident victims, or knowingly be disclosed to any third parry for the purpose of such solicitation, during the period of time that the information remains confidential. I am a party involved in the crash _ I am a legal representative to a party involved in the crash: Florida Bar Number _ I am a licensed Insurance agent to a party involved in the crash, their Insurer or Insurers to which they applied for Insurance coverage, Florida License Number I am a person under contractto provide claims or underwriting In formation to a qualifying insurance company, identified as: 1 am a prosecuting authority, Florida Bar Number _ I represent a radio or television station licensed by the FCC or newspaper qualified to publish legal notices or a free newspaper of general circulation, as defined in 316.066(2)(b) Florida Statutes. Name of Radio/Television/Newspaper 1 represent a local, state or federal agency that Is authorized by law to have access to these reports. Name of local/state/federal agency _ 1 represent a Victim Services Program, as defined In §315.003(BS), Florida Statutes (2014). Name of Program: Prin N T Agency Business Represented us (Area Code) Telephone Number city, State, Zip Code State of Florida, County of Swom (oraffrrmed) and subscribed before me this lgday of-��"FJt ' 201 by Personally known_or Produced Identification pe of IdentlRcation Produ C ✓ Print Type or Stamp, Commissioned Name of Notary Siggauure of Notary Public or Cefed Law H5MV-94010 (Rev.12/14) RENEE' ROWAN BASEL n : Notary Public • Stale of Florida Commission M GG 025209 M ••,Fa r�r` Y COP"', Expires Aug 28, 2020 Bonn��a,ign Nnsnna Not Asps DRIVER Lf C EhSE 01:.55 E `3 R263 - 39.0 DAVID TAYLOR ROUCHARD a, 7997 HE 34TH CT LIGHTHOUSE PONT. FL 33064 me 0649.1967 SEX M SSIEi3 ;.7.fF9M9 HGrlWW ' :d.N999: .`i 111.7A76 1. n.�.....+....s.r AM OPWAR s Gulf Stream Police Department e�� 246 Sea Road Gulf Stream, FL 33483 Phone: (561) 278-8611 Fax: (561) 276-2528 Page lof 1 Complaint Number: 17-1704 NON CRIMINAL OFFENSE REPORT Incident Type: TRAFFIC CRASH Location of Incident: 4140 N COUNTY RD GULF STREAM FL 33483 Type of Premises: HIGHWAY/ROADWAY Time of Call: 0929 Time of Arrival: 0931 Time Completed: 1015 Officer Injured: NO Date/Time Reported: 08/31/2017 09:29 Occurred From: Domestic: NO Juvenile Involved: NO Reporting Officer: OFC. RANDALL WILSON Name: DAVID T ROUCHARD Race: WHITE Date of Birth: 06/09/1967 Home Address: 1991 NE 34TH CT LIGHTHOUSE CT FL 33064 Name: MARY M G DONLEY Race: WHITE Date of Birth: 06/25/1940 Home Address: 4140 N COUNTY RD GULF STREAM FL 33483 REFER TO HSMV CRASH REPORT 87073102. Zone: Processed By: F OFC R WILSON Officer Killed/Assaulted: NO VICTIM Sex: FEMALE Cell Phone: (754) 224-1402 REPORTED BY Sex: MALE Cell Phone: (203) 979-0240 INCIDENT SUMMARY Ths Traffic Crash Repon can be purchased online at www buycrash cam WAS DOT PROPERTY INVOLVED IN THIS CRASH? FLORIDA TRAFFIC CRASH REPORT LONG FORM L] SHORT FORM Q UPDATE TOTAL # OF VEHICLE SECTION(S) 2 Ishil Anu) MAIL TO: DEPARTMENT OF HIGHWAY SAFETY 8 MOTOR VEHICLES TOTAL # OF PERSON SECTION(S) 2 TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING TOTAL # OF NARRATIVE SECTIONS) 1 TALLAHASSEE, FL 32399-0537 CRASH DATE TIME OF CRASH DATE OF REPORT REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 08/31/2017 9:29, 08/3112017 1 171704 87073102 CRASH IDENTIFIERS COUNTYCODE CITYCODE COUNTYGFCRASH School Bus Related PLACE OR CITY OF CRASH AND LONGITUDE H KI WI IN IME REPORTED TIME DISPATCHED 08 44 PALM BEACH 3 Dawn 4 Dark4.phtatl GULFSTREAM MILES CITY LIMITS �V 9:29 AM 9:29 AM TIME ON SCENE TIME CLEARED SCENE 1 CHECK IF COMPLETED RV REASON (11 investigation NOT Camplete) Notified By i Material 2❑ 9:31 AM 10:00,4 BB Unknown 88 Unknown 2 Cloudy 7 Severe CrosswiMs 2Law Enforcement ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS) 7 Forest Road Type of Shoulder CRASH OCCURRED ON STREET, ROAD, HIGHWAY Weather Condition ATSTREETADDRESSa School Bus Related © AT LATITUDE AND LONGITUDE COUNTY RO N 5 Dark -Not Ugh BDark-Unknown 4 Flog, Smog, Smoke 5 es ing a 1 Freezing Rein 4140 1 Na 2 Yee, Shod Bm 4 Sideswipe, same direction ❑6 5 Opposite Direction 3 Dawn 4 Dark4.phtatl AT MILES ,N 1 Directly ❑ INTERSECTION WITH STREET, ROAD,HIGHWAY © Rear to Si, to Slee ZIPCODE �OR FROM MILEPOSTS 300EET School Bbd 3 Yea, y ❑ 110 ❑ SEA RD BB Unknown 88 Unknown 2 Cloudy 7 Severe CrosswiMs Exwirp) 77 Other, 7 Dry 77 Omar, Explain In Road System Identifier 7 Forest Road Type of Shoulder TYpe of Intersection 5Trere Circle 1 Interstate 4 County ❑5 2U. S. 5Local 8 Private Roadway 9 Perkknp Lgt 1 Paved ❑2 2UnFaved to Front 88 Unknown TT 1 Not athaemection 2 atY Intersection 3T -Intersection 6 Roundaoout 7 Five -Point, or More 77 Other. Explain in Nanadve 3 State 6TumpikeRoll 770Mer, Expleln in N 3Curb First Harmful Event Non -Collision Collision Non -Fixed ObjectCollision with Fixed Object First Harmful Event N 4Y-Interseon I OVMUMRollaver 10 Pedestrian 19 ImpactAxenuator/Cresh 30 Concrete RASH INFORMATION (CHECK IF PICTURES TAKEN TAKE 2 FlrerEngloslon 11 Pedalcyrle Cmlon 31 Other Traffic Sellar Light Condition Weather Condition Roadway Surface Condition School Bus Related OWNER'S NAME Manner of Collision/Impact 1 Daylight Y 1 2 Dusk 5 Dark -Not Ugh BDark-Unknown 4 Flog, Smog, Smoke 5 es ing a 1 Freezing Rein 500 6 Mud, OirL Gravel 7 Sate 1 Na 2 Yee, Shod Bm 4 Sideswipe, same direction ❑6 5 Opposite Direction 3 Dawn 4 Dark4.phtatl Lighting T7 Other, Explain b B Slowing Sand, Soil 1 BWater 1 Directly ❑ ADDRESS Rear to Si, to Slee ZIPCODE Dirt 1 Cloud School Bbd 3 Yea, y 1 Front 7Rear 7 Rear to Rear to Rear BB Unknown 88 Unknown 2 Cloudy 7 Severe CrosswiMs Exwirp) 77 Other, 7 Dry 77 Omar, Explain In Ingot Indirectly Involved 77 Other. Explain In Nanetive 3 Rain 77 Omer, Explain N Narrative 2 Wet k R 2 on to Front 88 Unknown Nartative 41celFrost 88 Unknown 88 Un 3 Angle First Harmful Event Non -Collision Collision Non -Fixed ObjectCollision with Fixed Object First Harmful Event I OVMUMRollaver 10 Pedestrian 19 ImpactAxenuator/Cresh 30 Concrete 2 FlrerEngloslon 11 Pedalcyrle Cmlon 31 Other Traffic Sellar Location 1 On Roadway 74 3 Immersion 12 Railway vehicle (win, 20 Bridge Overhead Structure 32 Tree (standing) 2 Of Roadwa 4 Jackknfe engine) 21 Budge Pier or Support 33 Utility Pole Light Support 3 Shoulder 5 Cargo/Equipment 13Animal 22 Bridge Reil 34 Traffic Sign Support 1 4Median First Havofal Event Loss or Shig 14 Motor Vehicle In 23 Culvert 35 Traffic Signal Support 8Gore a FeNJumped From Transport 24 Curb 38 Ohter Post, Pole or 7 Separator within Interchange Motor Vehicle 15 Parked Motor Vehicle 25 Ditch Support B In Parking Lane or 1 No 7 Thrown or Felling 18 Work Zone/Melntalnance 2B Embankment 37 Fence Zone Object Equipment 27 Guardrail Fere W Mailbox 9 Outside Rlght-of-way 1 2 Yes 8 Ran Int Water/Canal 17 Stark By Falling, Shifting 28 Guardrail End 39 Other Fixed Object (wall, 10 Roadside 88 Unknown 9Other Collision Cargo 29 Cable Berner building, hunnel, etc.) Be Unknown 18 Omer NorvFlxsd Obiel First Harmful Event Relation to Contributing Circumstances: Road 9 Wom, Travel-Pdishetl Surface Contributing Circumstances: Environment 4 Junction 5 Raikvey Grade Creasing 10 Read Surface Condition (wet ❑ ❑ icy, show, slush, etc) —11NonJrdia 74 ErarencelExll Ramp 17 In Roadway❑ 77 Non -Junction 15 Crossover. Related Debris INone 12 Debris 2 Intersection 16 Shared -Use of Pam or Trail 13 Tmfx Control Device ( 4 Work ZonaconstructbNMissing 1 None 5 Animal(s) in Roadway 3lntenadion-Reletatl 77 ratioNDcelyretlon Lane melntenancaNNltY 2 Weather Conditions 7701her. Explain in 4 Driveway/Allay Access Through iBThrouph Roadway T7 Other, Explain In Narrative 14Non-HighywObawre0 7d Nan -Highway Work a Shoulders (none, low, sof, high) T7 Other, Explain in Nanafive 3 Obseudbn(a) Narratives Related 88 Unknown 7 Rut, Holes, Bumps 88 Unknown GlasPhysical 4 Glare 88 Un 88 Unknown Work Zone Related Crash InWork Zone Type of Work Zone Workers In Work Zone Law Enforcement In Work 1 Belong me First Work Zone 1 Lane Closure Zone Waning Sign 1 No 1 2 Yes 2 Advance Waning Nee 3 Themil Area 2 Lana ShBtiOrmsover 3 Work on Shoulder or Metlian 4 Intermittent or Moving Work 1 No 2 Yes ❑ 7 No 2 Officer Present ❑ 88 Unknown 4Activ Area 77 Other, Explain In Narrative 88 Unknown 3 Law Enforcement Vehicle 5 Termination Area Only Present TNESSES NAME ADDRESS VEH.s PERS PROPERTY DAMAGE -OTHER THAN VEH. EST. AMT OWNER'S NAME ❑ (CHECK IF BUSINESS) ADDRESS CITY &STATE ZIP CODE VEH.# PERM PROPERTY DAMAGE -OTHER THAN VER. EST. AMT. OWNERS NAME ❑ (CHECK IF BUSINESS) ADDRESS CITY &STATE ZIPCODE HSMV 90010 S 1 7 Page of VEHICLE# 1 Check if Commercial ❑ Reporting Agency Cess Number HSMVCm0 Report Number 3 Not In CommercelGovemmeM 171704 67073102 Ncn4 ollis[en 1 Vehicle In TransportVEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES Check H Permanent NN ocuipanM, including driver) 2 Parked Mohr Vehicle 1 3 Walking Vehicle TODDY JFL 0 1 Registrellorl ❑ LYV402HKOHB132774 6 Fell/Jumped From Motor Vehicle Ra erg Run 1 No 2Yes 88 Unknown 1 YEAR 201] S Ran Into Water/Canal MAKE VOLV MODEL SEDAN 1 Passenger Car STYLE 4DOOR SEDAN COLOR GRYIGRY DAMAGE: 1 Disabling 4 Mme 2Fundionel WUrik, ancon. 4 ESL AMOUNT $750.00 IfIbURANUE UUMPANY(mtlVtK) INSURANCE POLICY NUMBER 10000 due VEHICLE REMOVED BY 1. Rotation THE STANDARD FIRE INSURto Damage: 1 2. Omer Request 9817148172031 1No 2Yes DRIVER 3. Neer Explain In Nanetive NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ CURRENTADDRESS CITY &STATE ZIP MARY M G DONLEY 4475 N OCEAN BLVD NPT 440 DELRAY BEACH FL 33463 TmW LICENSE NUMBER STATE REGISTRATION EXPIRES CheckdPemlanent VW YEAR MAKE LENGTH AXLES One: Reglstreaat ❑ Trailer LICENSE NUMBER STATE I REGISTRATION EXPIRES Check if Permanent I VIN YEAR MAKE LENGTH AXLES Twp: Registration ❑ VEHICLE N S E W OR -Road Unknown I ONSTREET, ROAD, HIGHWAY AT EST. SPEED POSTEDSPEED TOTALLANES TRAVEUNG ❑ ❑ ❑1 ❑ ❑ ❑ COUNTY RD N 5 120 1 1 HAZ MAT. RELEASED HAZ. MAT. PLACARD NUMBER CUSS Area of Initial Impact Most Damaged Arae 1 No 1 Na 07 07 2Yes ❑ 2Yet ❑ 2 3 4 5 8 7 78 Umfercamage 1rn 8 2 3 4 5 6 7 BB Ungrgm 88 Unlmwm MOTOR CARRIER NAME US DOT NUMBER i4 15 16 17 BB 20 Wind19 shield 20 1 15 18 17 B 13 1211 D 21 Trailer 21 14 13 1211 0 g MOTOR CARRIER ADDRESS CfiV STATE nP CODE PHONE NUMBER Vehicle Body Type 15 Low Speed Vehicle CommiNan-Commercial TraRicway 3 Not In CommercelGovemmeM 4 Not in Commerce/Other Truck 18 (Sport) Utility Vehicle Ncn4 ollis[en 51 Twp -Way, Not Divided 8 Utility Tmller 88 Unknovm 2 FIMEnplaskin ocuipanM, including driver) 17 Cargo Van (10,000 lbs 14 4 JadNnBe 5 CargolEquipment Loss or Shift 2Txo-Way, Not Divided,.Ma 6 Fell/Jumped From Motor Vehicle occupants, including driver) 7Inman or Failing Object (4,536 kg) or less) S Ran Into Water/Canal 34 Traffic Sign Support Continuous Left Tum Lena 1 Passenger Car 181dolar Coach 14 14 40 equipment Failure (blovm 'mi 3Tao-Way, Divided, Unprotected 2 Passenger Van 19 Other Light Tnwks(I 0,0001bs Units 41 Ran Off on Roolmy, 42 Ran O0 Roadway, Right (painted> feet) Median 3 Pickup (4,538 Ng) or less) 44Cmss Median 4Rvo-Way, Divided, Positive 7 Motor Home 20 MeflumMeavy Trucks (more 39 Omer Fixed Object (well, Median Barrer 8 Bus then t 0,000lbs (4,538 kg)) Naretive 6One-Way Trafricvray 11 Motorcycle 12 Moped 13 All Tenaln Vehlue(AM 21 Farm Labor Vehicle 77 Other, Explain In Narrative 68 Unknwm CommiNan-Commercial ❑ llntarstate Carrier 2lnbestate Carrier 3 Not In CommercelGovemmeM 4 Not in Commerce/Other Truck Most Harmful Event Ncn4 ollis[en more men 10,0001lis (4,536 k9)) 1 CvenumlRollover 8 Utility Tmller 88 Unknovm 2 FIMEnplaskin ocuipanM, including driver) 3 immersion 14 4 JadNnBe 5 CargolEquipment Loss or Shift F1 6 Fell/Jumped From Motor Vehicle occupants, including driver) 7Inman or Failing Object Sequence of Events S Ran Into Water/Canal 34 Traffic Sign Support 90ther NarvCollaion 1st2M 140.46 Sequence of Events an, 14 14 40 equipment Failure (blovm 'mi INo brake feilum, etc.) Ira Units 41 Ran Off on Roolmy, 42 Ran O0 Roadway, Right ❑ 43 Ran Off Roadway, Lea 88 Unknovm 44Cmss Median 38 Mailbox 45 Cmaseninina F- -- - Commercial Motor Vehicle Configuration TRAILER 1 1 Vehde 10,000Ibis or less Placarded 8 TractorfTriple ❑2Seple-Unit for Hatamous Materials Truck(2axle and GVWR 9 Truck mora than 10,000 lbs (4,538 kg), Cannot Classify 5 Pao -Trailer more men 10,0001lis (4,536 k9)) 10 BuNLarge van (seats for 9-15 8 Utility Tmller 88 Unknovm 3 Single -Unit Truck (3 or mom axles) ocuipanM, including driver) 3 Curve Left 4 Truck Puking Traller(s) 11 Bus (seats for more than 15 F1 5 Track Tractor (bobtail) occupants, including driver) 11 Garbage/Refuse 6 Trod Tmctor/Sern[-Trailer 77 Otter, Explain In Nanedve 34 Traffic Sign Support 7 Truck TmdodDouble Truck 68 Unkrrvxm -- - Trailar Typo 1 Sini Serol Trailer B Pole Trailer TRAILER 1 TRAILER 2 2 Tandem Semi Trailer 9 Towed Vehicle 3 Tank Trailer 10Auto Transport Saddle MounVfmiler 77 Omar, Explain In ❑ Ch assis Container Charms El4 5 Boat Taller Nam6ve 5 Pao -Trailer 4 Uownhill 5 Seg (bailer) 1 8 Utility Tmller 88 Unknovm Comm 1 IaD00 lbs (4,536 k9) or lass GVWRIGCWR 210,001-28,000lot (4,538-11,783kg) 3 Mom than 28,000 Los (11,791 Collision with Non -Fixed Object 10 Pedestrian 11 Pedalcycle 12 Ralkvay Vehicle (barn, engine) 13 Animal 14 Motor Vehicle In Transport 15 Parketl Motor Vehicle 15 Work Zonesiaintanance Equipment 17 Swck By Felling, Shifting Capp or Anything Set In Motion by Motor Vehicle 1 46 Downhill Runaway 3 Turning Left 1 Level Vehicle Defects ❑ 2 Hillcrest Roadway Alignment Ch assis Container Charms 3 Uphill 14 Vehicle Towing 5 Pao -Trailer 4 Uownhill 5 Seg (bailer) 1 1 Straight 2 Curve Right 2 BusCargo 7 Flaged (vehicle 10,000Its 3 Curve Left Special Function 1 No Special Fustian F1 of Motor Vehicle 2 Fenn Vehicle 11 Garbage/Refuse Narrative 3 Pike 34 Traffic Sign Support 15 Mlrmra 7 Tax[ Guam, etc.) 8 Military 4 Backing 4 5 Turning Right 8 Changing Lanes 8 Parked 10 Making U -Tum 9 Ambulance 10 Fire Track 11 Farm Labor Transport 12 School Bus 13 TransieCommuter Bus Cargo Body Type Vehicle Defects ❑ 131nainer dal ed Box Ch assis Container Charms 4 Hopper 4Hopper ❑ 14 Vehicle Towing 5 Pao -Trailer Anomer Vehicle 1 No6 Cargo Tank 15 Not Applicable 2 BusCargo 7 Flaged (vehicle 10,000Its 8Dump (4,538 kg) or less not 9 Concrete Mixer displaying Placard pla 10Auto Transport 77 Other, Explain in 11 Garbage/Refuse Narrative 13 Stopped In Traffic 14 Slowing 15 Negotiating a Curve 16 Leaving Traffic Lane 17 Entering Traffic Lena T7 Omer, Explain In Nanstive 88 Unknown 14 Intercity Bus 15 Chamerfrour Bus 16 Shuttle Bus 17 Farm Labor Bus rmmc Control Device For Vehicle Defects ❑ 19 Impact AtienuatoritCrash Cushion 290ehle Barna Emergency 20 Bridge Overread Structure 30 Concrete Traffic Berner Vehicle Use 21 Bridge Pier or Support 31 Other Traffic Berner B Crossing 22 Bridge Reil 32 Time (stendirg) Device 45ehoal Zane SI9N 3Time 14 Wndowel 23 Culvert 33 Utility PolelLlght Support 4 Lights (head, Windshield 5 Traffic Comml Ragman, Officer, 34 Traffic Sign Support 15 Mlrmra Slgnal Guam, etc.) 24 Cum 35 Traffic Signal Support INo 25 Ditch 36 Omer Post, Pole, or Support 2 Yes 25 Embankment 37 Fence 88 Unknovm 27 Guardrail Few 38 Mailbox 88 Unknowm 25 Guardrail End 39 Omer Fixed Object (well, 13 Stopped In Traffic 14 Slowing 15 Negotiating a Curve 16 Leaving Traffic Lane 17 Entering Traffic Lena T7 Omer, Explain In Nanstive 88 Unknown 14 Intercity Bus 15 Chamerfrour Bus 16 Shuttle Bus 17 Farm Labor Bus rmmc Control Device For Vehicle Defects ❑ s Vehicle Flashing Signal ❑ ❑ NAMEOF VIOLATOR FL STATUTE NUMBER 1 Nona CITATION NUMBER 1 No Controls B Crossing 2 Brakes 13 Wheals Device 45ehoal Zane SI9N 3Time 14 Wndowel Device 10 Perean(includinp 4 Lights (head, Windshield 5 Traffic Comml Ragman, Officer, signal, Will 15 Mlrmra Slgnal Guam, etc.) 8 Steering 18 Truck Coupling B Stop Sign 77 Dither, Explain In 7Wlpers Trailer Hilal 7 YISM Sign Nanative 9 Exhaust System Safety Chains 88 Unknowm 10 Body Doors 77 Omer Explain I 11 PowerTmin Naretive PERSON# 1 NAMEOF VIOLATOR MARY MG DONLEY FL STATUTE NUMBER 316.1985(1) CHARGE SACKING -IMPROPER CITATION NUMBER Al PKXNP PERSON# NAMEOF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON# NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV 900105 2 7 PERSON# 1 Reporting Agency Case Number HSMV Crash Report Number 171704 57073102 1 Driver Nan-Motodst VEHICLE% NAME PHONE NUMBER Check it ❑ 2 1 RBCOmmend 3 Passenger MARY M G DONLEY 203 B7B-0240 ( ) Driver Re-exam CURRENT ADDRESS (Number and Street) CITY& STATE ZIP CODE 4675 N OCEAN BLVD APT 44G DELRAY BEACH FL 33463 DATE OF BIRTH SEX 2 ❑ DRIVERS LICENSE NUMBER STATE EXPIRES MNUORe SEVERITY (INJ)dlneapacltatlng 5 Fatal 06125/1940 2 Female 88 Unknown D-540.593.40-725-0 FL 2 0612512020 3 Passible (within 30 deka)El Non-Incapacitating 6 Non-Traffic, Fataiily DI-Type Required Endorsements lat Driven Actions at Time of Crash 3rd Condltlon At ❑ 1 A 2 B 3 C1 No Contribution Action 26 Ran 0 Roadway Time of 1 4 D/Chaulfeur � 1 Yes 2 Operated MV in Cia las or 27 Disregarded other Traffic Crash El 11 5 E/Opemmr 2 No Negligent Manner Syn 6 E/Oper-Rest 3 No Reg. Endorsement 3 Failed to Yield RyhWf-Way 28 Disregarded Other Road / Apparen0y Normal 7 Name 4 Improper Backing Markings 3Asi or Fadugnd Driver Distracted By 6improper Tum 29 Over-Coneckng/Over 8S5 111eRck) orFainted 4 Other Inside the Vehicle Steering spsy, Blackout (explain in narrative) 10 Followed too Closely 7 Physically Impaired 2nd 1 Not Distracted 5 External Distraction 11 Ren Red Light B Emotional (depression, 30 Swerved wAvoiCea :Due 4N 2 Electronic Communication (eulside me vehicle, explain ❑ 12 Drove too Fast far Conditions to Wind, Slippery Surface, MV, anghy, disturbed, eta) Devices (cell phone, etc. n nerta5va) 13 Ren Stop Sign Object Nan-Mdodst I B Under the Influence, of 3 Other Electronic Device BTenry 15 Improper Passing Roadway, air Medlcationsichugs/Aii (navigation dewire, DVD player) 7Ina0entive 17 Exceeded Posted Speed 31 Operated MV I Eml 77 Other, Explain In Narrative 88 Unknown 21 Wrong Site of Wrong Way Reckless or Agreeasive Manner 88 Unknown 25 Failed to Keep In Proper Lane 77 Omer Contributing Action DRIVER VISION OBSTRUCTIONS 1 1 Vision Not Obscured 5 Load on Vehicle B Smoke 2Inclement Weather 8 Builoing/Rxed Object 10 Gare DRIVER OR PASSENGER 4 3 Parked/Stopped Vehicle 7 SignRlilifted, T7AII Other, Explain 4 TreeuCmps/Bushes 8 Fag in Narrative Helmet Use (HU) Eye Protection (EP) Restraint systems DRIVER OR PASSENGER 7 OT-Compliant 1 Yee IRS) SEAT ROW OTHER Motorcycle Helmet 2 No ❑ ❑ Molar Vehicle Seating Position: LOCATION: 2Other Helmet 3 Not Applicable 1 Not Applicabb (non.motorist) Seat Row Other (LO) 1 1 3 No Helmel 2 None Used - Mater Vehicle Occupied 3 Shoulder and Lep Ball Used 1 LM 1 Not Applicable 4 Shoulder Bea Only Used 1 Front 2 Middle 2 Sleeper Section of Truck Cab Alr Bag Deployed p Belt Only Ueatl 2 Second p 5 Deployed-0ther 51-as 3 Right 3 Other Enclosed Carpo Aree Ejection (EJECT) (knee, air hart, etc) 6Restraint Used-Type Unknown 3Third 77 Other 4Unenclosed CargoArea 1Not Ejected 1Not Applicable 6Deployed. 7 Child Restraint System - Foresrd Facing (explain In 4 Fourth ❑ 2 Ejected, Totally 1 2 Not 0 e Child Restrant System - Rear Facing 5 Trailing Unit 1 Y B namtive) 77 Other Row 3 Ejected, 3 De loea Front 7 Deployed-nation B Booster Seat 80 Unknown BB Unknown 6 Riding on Motor Vehicle Exterior (north- Partially 4 DeployedI Be 7 Deployment in 10 Child Restraint a Unknown p Y trolling unit) 4 Not AppliaaMe UnknownDeployment 77 ether, Explain In Narrative 88 Unknown BB Unknown N 4aotari d Description 1 Pehesma^ F-12 Non-Motwht Location At Time of Crash 8 Sidewalk Action PNw to Crash ❑ f lnlersetaon- Marked Crosswalk ❑ 5 Welkin din on Sidewalk B 0 2 Othor Pedestrian sktrpe(wheelchah,person Ina building, skater, pedlesthen conveyance, etc 2 Intersection - Unmasked Crosswalk 10 Ohvewa Acral Gln Rg, Driveway Roadway Order (working, Y 3 -Marked Crosswalk 11 SharectUSe Roadway playing,etc.) Area it 1 Crossing ceotla 4 Other Cyraet OtherC 4Mitlbloch-Marked Croswalk 12 Nan rafficamy Rsoawry(e.g., Y 2 Waiting to Cron Roadway g t 5 Occupant d Motor VeMcte Not In Transport 5Travel Lane -Other Location shoulder, median) 88 Other, sin I Narrative 3 VJelking/CyrJing Abnp etc.) 6 Bicycle Lane nownRoadway with Trant:(in or 8 Going to critical Schad (K-12) e Owupantde Non-Motor Vehicle 6 Occup 7 shoulde/Roatlsle BWondtnp In TreRcxey adjacent to travel lane) 9Workitg in Trail Transportation Device on o o • ons rcuma nces 4 Waiking/Cycling Along 10 Nona 7 Unknown Type d Nan-Motorist Ir❑ INOlmproperAction Roadway Against Tmft(in 77 �aq Explain In Narrative Other,Unknown DarVDash or adjacent to travel lane) 6g 3 Failure to `Held Rightaf-Way 4 Failure to Obey Treffia Signs 7 None Safety Equlpmant 5 Ughtiry 2 Helmet 6 NotApplicable 3 Protective Pads Used Signals, air Officer EntennyExllin9 Perked5tendinp 10mproper inerya am 51n Roadway Im VehicleVehicle 11 Improper Pas PesNty 77 Omer, Explain (elbows, knees, shins, em) I Narrative ropady (standing, lying, working, playing) 8lnadentive (talk4p, eating, etc) 12 Umar ay Riding or Welting 4 Radiative Clothing (Jacket Be Unknown ❑ 6 Disabled Vehicle Related (working B Not Visible (ders clothing, nO T7 Other, Explain In Narrative backpack, em) on, pushing, leaving/approaching) lighting, em) Be Unknown ALCOHOLIDRUGIEMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE:[ALCOHOL BAC SUSPECTED DRUG TESTED: DRUGTESTTYPE: DR UG TEST RESULTALCO: 2 Yes USE: ❑ venI Test Not i ndn ❑ 3TnlGative Breath 77 O1herI Blood 2Explan ❑2COMPLETED❑ YesG USE: 1 Test Not Given3 Test Gliven�MTe1:1ExplaininN3 1 Blood 1 Urine❑ertetive Positive Pending ❑ BB Unknown 88 Unknown, OTesled In Narrative BB UNKNOWN 8Unknown Unknown SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Trampomed 2EMS 31LMEnforcement 1 77 Omer, Explain In Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON %VEHICLE# AME DATE OF BIRTH I INJ I SEX LOGS R O EJECT HU EP ASO R6 CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACIUTY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO r xan..w.axew si..e .n nr ..r . x.r,.ruew.. ❑ PERSON %VEHICLE% AME ATE OF BIRTH INJ I SEX LOC:S R 0 EJECT HU EP ABC RS CURRENT ADDRESS (Number and Street) CRYSTATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO r xen..r.mxews u. ew.�.snoei.. rmwe x.ir.ruw... ❑ HSMV DDD10 S NARRATIVE Repo 61' Agency Case Number HSMV Crash Report Number CHARGE 171704 87073102 Driver of V-1 was backing out of her private driveway onto N. County Rd. She violated the right of way of V-2 by backing into the roadway striking V-2 in the right front fender. The driver of v-1 said she could not see because hedges were blocking her view as she backed out of the driveway. ADDITIONAL PASSENGERS PERSON # I VEHICLE # AME DATE OF BIRTH I INJ I SEX I LOGS I R O 1 EJECT HU EP ASD I RE CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO N u..UW q , ]] �]EYYwEn�amnf ])fIM,frpwF 1:11 PERSON# VEHICLE# rME DATE OF BIRTH INJ I SEX LOGS R 0 EJECT I HU I EP I ASD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMB RUN NUMBER MEDICAL FACILITY TRANSPORTED TO wpnsl ir^EN9llw Enban�nr l] plw. E4Yn n ADDITIONAL VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON# NAMEOF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER ID]SADGE p RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. 755 OFC R. WILSON GULF STREAM POLICE DEPARTM POLI CE DEPARTMENT PO HSMV 90010 S QIAGRkA REPORTING AGENCY CASE NUMBER 171704 HSMV CRASH REPORT NUMBER 87073102 Di gr m not 0 required HSMV 80010 S 5 n VEHICLE# 2 Check if Commercial❑ Reporting Agency case Number HIS sh Report Number 71704 97073102 1 Vehicle In Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRESVIN Check 8 Permanent 2 Parked Motor Vehtcte 1 HV2:101 FL 3 Waking Vehicle O6I30/2019 Replatratien ❑ 5TDJKRFH5FS211796 1 NondRun YEAR MAKE MODEL STYLE COLOR DAMAGE: 1 Disabling 4 Minor EST. AMOUNT 2 es1 201$ TOYT $UV UTILITY MAROON, 4 2Functlonel 88 UnMawn ❑ $1rDDD.DD 88 Un 88 Unknown BURGUNDY (PURP 3 None INSURANCE COMPANY (DRIVER) STATE FARM MUTUAL AUTOM INSURANCE POLICY NUMBERTowed due b Damage: 1 VEHICLE REMOVED BY 1. Rotation 2. Owner Request 000/244584 true 2Ves DRIVER q; ODriver Explain In Naeativa NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ CURRENTADDRESS CITY &STATE ZIP DAVID TAYLOR ROUCHARD 1991 NE 34TH COURT LIGHTHOUSE POINT FL 33064 Trager LICENSE NUMBER STATE REGISTRATION EXPIRES Check d Permanent VIN YEAR MAKE LENGTH AXLES One: I Registration ❑ Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check VIN YEAR MAKE LENGTH AXLES Two: I Upranent Registration ❑ VEHICLE N S E W Oft -Road Unknown ON STREET, ROAD, HIGHWAY AT EST SPEED POSTED SPEED TOTALLANES TRAVELING 1:12 ❑ ❑ ❑ ❑ I COUNTY RD N 20 20 1 1 -AZ. MAT. RELEASED 1 Na HAZ. MAT. PLACARD 1 No NUMBER CLASS Area d Initial Impact Most Damaged Area 03 03 2Vea 88 Unknown ❑ 2Yas Be Unknown ❑ 5 6 7 1B Underwniaga to 2 3 4 5 6 7 16 17 8 1B Ovarium 19 1 1$ 18 17 B 20 Wndahield 20 MOTOR CARRIER NAME USDOTNUMBER 14#11 0 9 21 TRI# 21 14 13 1211 0 9 MOTOR CARRIER ADDRESS CITY STATE 21PCODE PHONE NUMBER Vehicle Body Type 16 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 18 (Spon) Utilfty Vehitle 1 Two -Way, Not Divided 1 Vehicle 10,Og01bs a less Placarded B TractorRnple 16 $ Hazardous 9 Truck more Nen ig000 me (4,538 17 Carpo Van (10,000Ibe 2Two-Way, Not Divided, with a ❑ 2 = Gals (4,535 kg) or leas) Continuous Left Tum Lana 251npIo-UMlTrud(2-axle and GVWR kip), Cannot Classify 1 Passenger Car 13 Motor Coem 3 Pwo-Way, Divided, UnpmteCed more than 10.000 lbs (4EW kg)) 10 Bus large van (seats for 9-15 2 Passenger Van 19 Other Ught Trucks (ID,000Ibe (painted>4 feet) Median 3 Singe-Un8 Truck (3 or more axles) occupants, Including driver) 3 Pickup (4,536 kg) a leas) 4 Two -Way, Divided, Positive 4 Tnrck Pulling Trade 11 Bus (nets for more Nan 15 7 Motor Home 20 Mediuml-leavy Trucks (more Median Barrer 5 Truck Trador(bobtail) occupants, Induding driver) S Bus than 10,000 los (4,538 kg)) 5 One -Way Trefficway 6 Truck Trector/Seml-Trailer 77 Other, Explain In Namerve 7 Truck Tractor/Double Truck 88 Unknown 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 12 Mopad 77 ONar, Explain in Narrative Trailery Skple Se M Trailer B Pole Trailer 13 All main VehkAe (ATV) 88 Unknown 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type Corom/Non-Commerclal TRAILERI TRAILER2 131ntemrodal 3 Tank Trailer 10AONTramport 3VaaEnclosed Box Container Chassis Saddle nVTreger Narrieve Explain In 4 Hopper ❑ 1 Interstate Canter ❑ ❑ 1AnotherVehicle ❑ ZNotin ateCo Cemler 5Pole Trailer Vehicle� 8 Unary Taalr4 3 Not In Lommema/Govemment 6Cargo Tank 75 Not Applicable 7 House d Nat In Commelce/OtherTrurh Trailer 1 Na Cargo 7 FMNed (vehicle 10,000Iba 1 10.000 Me (4,538 kg) or leas 2 Bus 8 Gump (4,538 kip) w lase not Most Harmful Even t Norturn( lalan Comm 2 10,001-28,000les (4,SWI 1,793kg) 9 Connate Mixer displaying 10vertuplosioaver GVWR/GCWR `1 3 More than 28,000 lbs (11,793kg) 1OAuto Transport 77 Col. ExplaininZ 4NotA Applicable 3lmmereien 11 Gamege02eNae Naeativa ImmFire/ersion 4 Jackknife Collision with Non -Fixed Object Collision Fixed Object 12 Log 88 Unknown 14 5 Cargo/Equipment Loss a Shift /O Pedestrian 29 Cable Barrer Emergency 6 FelWumped From Motor Venice 11 Pedalcycle 19 Impact Aftenuator/Crash Cushion 30 Concrete Tre1fic Bonier Vehicle Use Concrete reteTr Banner 7 Thrown or Falling Object 12 Railway Vehicle( train, engine) 20 Bridge Overhead SlruGure 31 21 Bridge Pier w Support Sequence of Events 90therinto WaterlCanel 131imlor 32 Tree(etandinp) 90ther NonColliaian 14 MotorVMideln Tren 22 Bridge Reil Spon 33 UUdy Pole Support 1 23 Culvert b Support a 1S Parked Motor VMicle 34 Traffic Sign l Sup [40.18 Sequence o/ Events only) i6 Work Zone/Maintenance 24 Cwb 35 Trema Signal Support 1 No 14 14 40 equipment Failure (blown tire, Equlpment 25 Ditch 36 Other Post, Pole, or Support y gee brake rallur ,etc.) 17 Struck By Fell Shill lrp Cargo or 26 Embankment 37 Fence 88 Unknown 41 Separation of Units Anything Set In Motion by Motor 27 Guardrail Fete 38 Mailbox 4th 42 Ren Ort Roadway, Rlpht Verde 28 Guardrail End 39 Other Fixed Object (wall, 47 Ren OR Roedwey, LeM1 18 Other Non-lci Ob' bulldin funnel etc. ❑ 44 Cress Meelen Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Cress Cenledine 3Tumiht Mead 13 Sown, In Traffic This Vehicle ❑ Roadway Gratla 48 DownhNl Runaway 3 Tumaq Ah 14 Stowing 1 Level ❑ 4 Smiling 15 Negotiating a Curve 1 8 Flashing Signal 1 thane 2 Hi creel 1 5 Turning Right 18 Leaving Traffic Lane 9 RaiMay Creaallq Roadway Alignment iNoCenbda 2Brakes 13 Wheels 1 3 Uphill 6 Changing Lanes 17 Entering Traffic Lane Device 4 SUw°I Zane Sign/ 3 Tires 14 Windows/ 4 Downhill t Straight 8 Parked 77 Other, Explain In Narrative 10 Person (Including Devka 4 Lights (head, Windshield 5 Seg (boom)1 2 Curve Right 10 Making U -Tum BB Unknown Flagman, Officer, 5 Traffic Control signal, tail) 15 Marva 3 Curve Left 11 Ovrxtakin Basin Guard, etc.) Sl1 77 Other, Explain In 7Wpersp 16Trurk Coupling tophall Special Function 14 Memory BStop Sign Trailer I No2Fa Narrative 9When 101cha Truce Vehicle ChartrBen 1 2 Foam VehiCb 10 Fire Truck 15 Bus 7 Ybid Sign 9Body.Exhaust System Salary Chain Vehicle of Motor Vehicle BB Unknown 3 Poke 11 Farm LaborTrenapon 18 ShuNe Bus 10 Body, Doom 77 Dther, Explain In Shuttle Explain 7 Text 12 School Bus 17 Farm Labor Bus 11 PowerTram Narrative B Military 13 Transit/Lanmuler Bus Be Unknown 12 Suspension Be Unknown VIOLATIONS PERSON NAMEOF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON# NAMEOF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSONS NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV90010S 6 7 Page o1_ PERSON# 2 Reporting Agency Case Number HSMV Crash Report Number •1 171704 57073102 Driver 2 Nan-Motorist VEHICLES NAME PHONE NUMBER Check ❑ i 2 Recommend 3 Passenger DAVID TAYLOR ROUCHARO (75412241402 Driver Reavam CURRENT ADDRESS (Number and Street) CITY& STATE ZIP CODE 1991 NE 34TH COURT LIGHTHOUSE POINT FL 33064 DATEOFSIRTH SEX: 1 ❑ DRIVERS LICENSE NUMBER STATE EXPIRES ;MNUORe SEVER"(INJ)4lncapectteting 5 2 Farads 2 Poaside Fatal (within 30 days) 0610911967 88 Unknown R-263-178-67-209-0 FL 06/09/2015 3 Non-Incapadtetlng 8 NW-Traffic Fatality DL Type Required Endowments tat Driven Actions at Time of Crash 3rd Condltlan At ❑ t A 2 8 3C 1 No ContrloutlonANon 28 Ran o0 Roadway Time of 1 4 four lyes 2 0perebd MV in Carelss or 27 Disregerdetl other Tretgc ❑ Crash ElOpe 5 ElOperaw 2 No Negligent Manner Sign 6 Eloper-Rest 3 No Req, Endorsement 3 Fixed! to Yleid Rightaf-Way 28 Disregarded Other Road 1 Apperen0y Normal 7 None 4 Improper Backing Markings 3 Asleep or Fabuged 0Improper Tum 29 Oves-Comecang/Over 5 111BSebure,E Fainted iin sd, Dover OHiremed By 4 Other Inside the Vehide Sharing W PY Blackout 1 Not Distracted (explain In narrative) 2� 10 Followed too Closely 7 Physically Impabed 5 External Disbacion 11 Ran Red Light W Swerved or Avoided Due B Emotional (depression, 2 Electronic Communication (ouLNde the vehicle, explain 12 Drove ted Fest for Cone itlom b Who, SII 4M angry, disturbed, etc) Devices lead phone, etc In nanabva 13 Ran S Sign Slippery l r st In MV ❑ 9 Under the Influence M 3 Other Electronic Device ) g octet In B T Passing ek. MadicadonalD l al 17 Roadway. ale. (navigation devlco, OVO ser player) ) atter 17 Exceeded ExplainIn rr Si Pooled Speed 37 Operted MV In Ene 31Open 88 Other. In Narrative N Unkntive Wong BB Unknown 21 Wrong Side of Wrong Way Reckless arAgrensHe Manner M DRIVER VISION OBSTRUCTIONS 25 Failed to Keep In Proper Lane 77 Other Conbibuting Action ❑ 1 Vision Not Obscured 5 Load on Vehide 9 Smoke 2Inclement Weather 6 BuddinglFixed Object 10 Glare DRIVER OR PASSENGER 1 3 Parked/Stopped Vehide 7 Slgns8llbcams 77 All Other, Explain 4 TreeslCmpslBushes 8 Fog In Narrative Hainaut Usa (HU) Eye Preelection (EP)Reaoalnt Systems DRIVER OR PASSENGER ❑ 1 DOT-Compliant 1 yes El IRS) SEAT ROW OTHER Motorcycle Helmet 2N ❑ Motor Vehicle Seating Position: LOCATION: 2Oher Helmet 3Not Applicable 1 Not Applicable(non-motorist) Seat Row Other (LOU) 1 1 3N Helmet 2Naze Used- Motor Vehice Occupant a 3 Shoulder and Lap Belt Used 1 Left 1 Not liwble 4 Shoulder Ball Only Used i Front PP Alr Bag Deployed 2 Middle 2 Second 2 Sleeper Section of Truck Cab 5 Deployed-0mer 5 Lep Belt Only Used 3 Right 3 Other Enclosed Cargo Area Election (EJECT) (knee, air belt etc) 8 Reactant Used-Type Unknown 77 Other 3 Third 1 Not Elected 1 NotA 7 Child Restraint S 4 Unenclosed Cargo Area ppOcabla 6Deployed. ystem- Forward Fadrg 2 (explain In 4 Fourth ❑ 2 Ejected, Totally 2 Not D d ed B Child Restraint System - Rees Facing 5 Trailing Unit 1 Combination y g na Unkox 77 pylar Raw 3 Ejected, 3 De oyes Front B amateur Seal 88 Unknown 8 Riding on Motor Vehicle Exterior (non- Partially PI Y 7 DepldyedLurtein 10 Child Reatrelnt Type 88 Unknown Y 4 Deployed-Side 88 Deployment Unknown trailing unit) 4 Not Applicable Unknown 77 Other, Explain m Narretive 88 Unknown Be Unknown N Motadst Oescdpdon F-12 Non-Motodst Location At Time of Crash 8 Sidewalk Action Peter to Crash ❑1lritereeaon-Marked Crosswalk 9MadieNCreeatn Island ❑ 5 Welking/Cyding on Sidewalk Other 2 Other Pedestrian (wheekhad, person In e 9 2lntersecton- Unmarked! Cressrsik Bln Roadway—Other building, skater, pedestrian conveyance, etc. 10 Driveway Access (working, 3 Bicyclist Mibloc Marked Crosswalk 11 Shared-Use Path or Troll 1 Creasing Roadway 7 yinAdjg,stc.) Cyclist OtheOccupant 4Mlerseesblock Marked Crosswalk 2 Waiting to Cross Roadway to Reodway (e.g„ reExplain 5 Ocapent al Motor Vehicle Not In Transport 5 5 Travel Lane -Omer Location 77 Other,12 In Nanedve Along shoulder, median) 3 WalkRoadway III a Bicycle Lane 98 Unknown Roadwaywird Traffice) or B Going to dr from Bowel (K-12) Tea 8 Ocoupent of a Non-Morar Vehicle 6 Occupant of 7 shoulder/Rdadsbe adjacent to travel lana) 9YVeang in TraBaway 7fenslmnadTy Devic on- o on rcums nus 4 Walking/Cycling (Incident response) Alonp 10 None 7 Unknown Type of Noo-Matadet ❑ 1 No e rAction Roadway A Against Tremc (in tat 77 Explain n Narrative ruDash to teal 2 Failure to or etljecent to travel lane) Unknown 3 Failure to YieldObs Right--Way 00 Unknown 4 Failure to Obey Trelfle Signs 1 None Safety Equipment 5 UghWg 2 Helmet 6 Nother, Ex bb 3 Protective e Paris Used e ❑ 5I Signals .1OfficerImp 7 hide lEktlng PerkedSMMinp 11 Improper Tum/Merge dna 51n Roadway Vehicle 11 Improper k in per, Explain , leasee, shins, aces Imaying) (standing, eating, Wrong-Way Rlding or Walking lying, working, playing) B 72 ay Riding (dark 8NarrativeU no 4 Refle 4 Reflective Clothing 0erkeL 88 Unknown Not Cl o Other, 6 Disabled Vehlele Related (working li Not Vleble (dark ctothlnp, raw 77 Other, Explain In Narrative backpack, etc) on, pushing, Ieavinglepp�ching) tlphan9, e1c.) 88 Unknown ALCOHOLIDRUG/EMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE[ALCOHOL SAC USPECTED DRUG TESTED: DRUG TESTTYPE: DRUG TEST RESULT' SE: No U88 �1 Not Given l t ❑ ULT ❑ ❑ DRUG USE: I ❑ Test Not Given6 11 ative ending 11 2YesALCO 2Yee Give COMPLETED O SEN 2Yes 3 Test Given 77 Ott r, n 88 neS Tea InN�llv�en Off nom Teat SOURCE OFTRANSFORTTO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILTTY TRANSPORTED TO 1 Not Transported 2EMS 3Law Enforcement 1 77 Other, EVIann in Nanetive BB Unknown AOOITIONAL PA98ENGER9 PERSONS VEHICLES AME DATE OF BIRTH I INJ I SEX LOC:S R O 1 EJECT I HU EP ABC I RS CURRENT ADDRESS (Number and Steeq CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACIUTY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO t e.n...aaa ares w ws,.s nam.. em+. w anen.eeu+...i PERSONS VEHICLES ME DATEOFBIRTH INJ SEX LOC:S R O EJECT HU EP ABD I RS CURRENT ADDRESS (Number and Sheet) CITY I STATE ZIP CODE SOURCE OF TRANSPORTTO MEDICAL FACILITY EMSAGENCYNAMEORID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO I ex n.s.rx suss nce�,esaw e ❑ xmrwmuwem HSMV 90010E 7 7 Page of_