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HomeMy Public PortalAboutPRR 17-2590 Renee Basel From:Winston Reid <wreid@pbhab.com> Sent:Wednesday, September 20, 2017 4:43 PM To:Renee Basel Subject:RE: Gulf Stream Crash Report Attachments:DOC092017-09202017.pdf From: Renee Basel \[mailto:RBasel@gulf-stream.org\] Sent: Wednesday, September 20, 2017 1:29 PM To: Winston Reid <wreid@pbhab.com> Subject: Gulf Stream Crash Report Good afternoon, Mr. Reid: After speaking with you on the phone earlier today, I spoke with our Chief of Police. Crash Information is confidential and exempt from disclosure for a period of 60 days after the crash report is filed unless you were involved in the crash, etc. I am attaching a form that needs to be filled out and notarized before I can get this info to you. I am a notary, so if you just want to come into the office, just let me know and I’ll have the report ready for you if you meet the requirements in the Sworn Statement that is attached. Have a GRAND day! Reneé Rowan Basel Executive Administrative Assistant Town of Gulf Stream 100 Sea Road Gulf Stream FL 33483 561.276.5116 561.737.0188-fax www.gulf-stream.org Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s). If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. Florida has a very broad public records law. Written communications regarding Town of Gulf Stream business are public records available to the public upon request. Your e-mail communications are therefore subject to public disclosure. Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing. 1 TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered via a -mail September 22, 2017 Winston Reid [mail to: wreidapbhab.coml Re: GS #2590 (Crash Report) Would like a copy of the police crash report #17-1809. Dear Winston Reid [mail to: wreidapbhab.coml: The Town of Gulf Stream has received your public records request dated September 20, 2017. I have attached the report to the e-mail for your convenience, as Motor Vehicle Crash Reports are confidential for a period of 60 days after the report is filed and they are not available to the general public during this time. On November 20, 2017, after expiration of the 60 -day period, per Florida Statute 4 316.066(2)(a), you should also be able to view your original request and response at the following link: b=://www2.gulf-stream.ore/weblink/O/doc/112968/Pagel aspxx We consider this request closed. Sincerely,, t ko*O( As requested by Rita Taylor Town Clerk, Custodian of the Records Shorn Statement for 7rafft Crash Report lnformatlon Motor Vahtda aath)nformatlon Is confldonVal and exempt from dWasurefora period of 60 days afar the trash report is filed, 69164166(2)(a)Fl0ftStQlutn(10U), ObtalningmMldentlalInformation byAameonewho knows they or* not artdtled to do so b a fabrry Wobltam vywa.a unrw, mg cram r port(thoo locadontpord b 17 The undanyrmdstates that he/the or the organttatMnrepresent edquatffyforlmmediatedladoturoofthacrash re report atcorMn6tothaoxempdonchecked bolowanddoasewearorafHrmthat the Information conbinedIna cWhrop ����e� oudidendalbystatute will not beused for any eommtrcbl solids atlanofealdentvkUMorWww F°rcmada/�n5b&e5 thkdparty for the purpose ofauchaol"010n, during the pedadottime that the bdormatlonnm►t � d�osedt*any Pere z - ZInnapariylnvahredinthecrab —1 am a 10601 represamative to a party ImraNed M the crash: Florida Oar Number _1amolicensedlalurancestenttoapartyInvolvedMtheaeshtheirIm rarcrinsurers to which they applied for Imurance coverage, Florida License Number —lam a person under contractto'provide daims orunderwrhing in formation to 0 qumJlf g insurance company, ldamifled as: _ 1 em a prosacudng authority, Florida Bar Number Y.,1 represent a radio or television station licented by the FCC er newspaper qualtlied to publish legal notices or a free newspaper of 6onaral circulation, as defined in 616.066(2)(b) Florida Statutes. Name of Radlo/rolevislo"Mr*spaper 1 roprasahta local, stab orfederal Igeacy that Is sulhorited by law to have access to these leporb. Name of logl/state/fadaral agency ,._I sspreeent a Victim Services FrOln", as defined In fals.00g(eS), "Grids Stacutaa (2uLt), Name of provern:-- Ott, zip Code > a ofikrw,county of Palms iCti Q lcor�FRwrdaubsaWodMfaremaW)of /e �z0)%11y p!tsane/ykhown�or produced Moritt�tatlorr�lypdof We"Wiatlon Wo4owt, FAmtypeor6pinpCompdtakmadNNnaolNoptry NohtryhlyNeort�rHgedtow tlnfe+arriint or Correctkegt Ofllier "SMV -04o10 (ReV,12/14) This Traf . Crash Report can be purchased onthe at rmvwbap.mah com WAS DOT PROPERTY INVOLVED IN THIS CRASH? FLORIDA TRAFFIC CRASH REPORT LONG FORM SHORT FORM V_ UPDATE TOTAL # OF VEHICLE SECTION(S) 2 Ishsamrviesi MAIL TO: DEPARTMENT OF HIGHWAY SAFETY &MOTOR VEHICLES TOTAL # OF PERSON SECTION(S) 3 TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING TOTAL # OF NARRATIVE SECTION(S) 1 TALLAHASSEE, FL 32399-0537 CRASH DATE TIME OFCRASH DATE OF REPORT REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 0911812017 11:00 AM 09118/2017 171809 87073103 CRASH IDENTIFIERS COUNTYCODE CRYCODE COUNTYOFCRASH PLACE OR CITY OF CRASH MEIEPORTED TIME DISPATCHED 08 44 PALM BEACH GULF STREAM Crry LIMITS 11;04 AM 11:04 AM TIME ON SCENE TIME CLEARED SCENE CHECK F FV Notified (H Investigation NOT Complete)COMPLETED No1Med By'1Motorist 11:08 AM 11:45 AM 2 Law Enforcement ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAY AT STREET ADDRESS# In © AT LATITUDE AND LONGITUDE S.R. AIA IN. OCEAN BLVD.) 1300 ql reel mILCa n a e vv glltHUM INIaHSGL IIUN WITH 51 REST, ROgD,HIGHWAY NAME Manner of Collision/Impact FROM MILE POST# 5 Derk4Jol L mad b 6 Dark -Unknown 4 Flag, Smog, Smoke 5 emong Ra 1 Freedng Rein ❑ ❑ ❑ ❑ 1300 BLOCK OF SR AIA ❑3 4 Sideswipe, same direction 5 Sideswipe, Opposite Dre tion 3 Dawn 4 Dark -Lighted �OR Road System Identifier 7 Forest Roatl Type of Shoulder Directly Involved T pe of Intersection 5 Traffic Ci 3 B Pm ate Roadway 1 Interstate 4 County B Parking Lot 2 U.5. S Local 1 PaveO 2 2 Unpaved 3 i at et Intersection 2 Four -Way Intersection 3 T. permeation 6 Roundabout 7 Five -Paint, or, More 77 Other Ex len In Nei 3 State 6 TumpikeRoll Nandi77 Other. Explain In Nertative 3 Curb 2 Wet Narrative 4 Y-Imersection p RASH INF RMATI N ( HE K IF PICTURES TAKEN) Nall Light Condition Weather Condition Roadway Surface Condition School Bus Related NAME Manner of Collision/Impact 1 Daylight Y IB 1 2 Dusk 5 Derk4Jol L mad b 6 Dark -Unknown 4 Flag, Smog, Smoke 5 emong Ra 1 Freedng Rein 5 Oil 8 Mutl, Din, Grewal 7 Sark 1 No 2 Yes, School Bus ❑3 4 Sideswipe, same direction 5 Sideswipe, Opposite Dre tion 3 Dawn 4 Dark -Lighted Ughtirp 77 Other, Explain In 6 Blowing Sand, Soil B Water Directly Involved 8 Rearm Side Narrative as Unknown 1 Clear DiM1 2 Cloud 7 Severe CrosswlMs (efandinglrttovinB) 1 Dry 77 Other, Explain In 3 Yes, School Bus Indi Involved 1 Fmnl to Rear 7 Rear to Rear 77 Other, Explain in Nanative 3 Rainy 77 Other, Explain In 2 Wet Narrative 2 Front to Front 99 Unknown Nall 41ce/Freat 88 Unknown 3 Angio First Harmful Event Non -Collision Collision Non -Fixed Object Collision with Fixed Object First Harmful Event 10vertumlRollover 10 Pedestrian 191mpactAttenuator/Crash 30 Comate 14 2 Fire/Explosion 11 Rsaalcyde Cusion 31 Other Traffic Bamer 3Immersion 12 Railway vehkJe(gain, 20 Bridge Overhead Structure 32 Tree(standing) Location y 1On Radi 200 Roadway 4 Jackknife enOthe) 21 Bridge Pier or Support 33 Usry Pole/Light Support 3 Shoulder 5 CaigolEquipment 13 Animal 22 Bridge Rail 3a Traffic Sign Support 1 4Median First Harnful Event Loss or Shift 14 Motor Vehicle In 23 Culvert 35 Traffic Signal Support 6 Gore B FeIVJumped Fmm Transport 24 Cum 36 Dinner Post, Pole or 7 Separator within Interchange Motor Vehicle 15 Perked Motor Vehicle 25 Dtaft Support a In Parking Lane or 1 No 7 Thrown or Felling 16 Work 2cna Maintainance 25 Embankment 37 Fence Zone 1 2 Yes Object Equipment 27 GuaNte rall Fe38 Mailbox 8 Ran Int Water/Canal 17 Slouch By Felling, ShOung 2B Guardrail End 39 Other Fixed 9 Carbide Rlghtaf-way 88 Unknown Object (wall, 9 Other Collision Cargo 29 Cable Banner Wilding. Wnnel, ei 10 Roadside 88 Unknown 18 Other Non-Fixea Otnect First Harmful Event Relation to Contributing Circumstances: Road g Wam, Travel -Polished Surface Contributing Circumstances: Environment 3 Junction 5 Railway Grade 10 Read Slush. Cantlitian (wal snow, slush, etc) 1 El El ❑ RampCrossmg 14 Ramp 11 11 ObsasNan In Roadway ❑ ❑ ❑ 1 Non,lundion Crossover- 15 Crossover Related 12 Octans 1 Nona 2 Intersection 15 SharetlAseolllimm Pam Tr ell 13TreftioControl 4 Work Zone (ifildy N I None2Weat Roadway 3 IntenreDnvewatioroRelatedAcce 17 o tion Lana Misekg or Obscured! Missing Obsaretl malntelders(none 2 Weather Conditions 77 Other, Explain in T7 Other, Explain Through to Through Road way Roadway 14 Nontiva 14 Work ghwai Work 3Glare lObaWdlon(e) Related y/Alley Access 77 Omar Explain In Nertative 8 (none, low, soft, nigh) 77 Other, Explain In Nartative Other. Related BB Unknown 7 Rut, Mdea, Bumps BB Unknown Rut, 4 Glare 68 unknown 88 Unlowwn Work Zone Related Crash in Work Zone Type of Work Zone Workers In Work Zone Law Enforcement In Work 18efaa Me First Work Zone 1Lane Closure Zone I No 1 2 Yes Warning Sign 2Advance Worming Area 3 Transition Area 2 Lane Shift/Cressover 3 Work on Shoulder or Median El 4 Intermittent or Moving Work 1 No 2Yes ❑ 1 No 2Offcer Present ❑ BB Unknown 4 ANvltyArea 77 Other, Explain in Nami 08 Unknown 3 Law Enforcement Vehicle 5 Termination Area Only Present TNESSES NAME LENNY KREUSHER ADDRESS 3BO NW 40TH ST. CITY &STATE BOCA RATON ZIP CODE FL 33431 NAME ADDRESS CITY It STATE ZIP CODE NAME ADDRESS CITY&STATE ZIP CODE NON VEHICLE PROPERTY DAMAGE OWNER'S NAME ❑ (CHECK IF BUSINESS) ADDRESS HSMV 90010 S 1 8 Page orf_ PER# ROPERTY DAMAGE -OTHER THAN VER. EST AMT. OWNER'S NAME ❑ (CHECK IF BUSINESS) ADDRESS CITY &STATE LP CODE dVER.# VEH.# PER# ROPERTY DAMAGE - OTHER THAN VER. EST. AMT. OWNER'S NAME ❑ (CHECK IF BUSINESS) ADDRESS CITY &STATE ZIP CODE HSMV 90010 S 1 8 Page orf_ VEHICLE # 1 Check if Commercial ❑ Reporting Agency Ceae Numbor HS MV Crash Report Number CHARGE CITATION NUMBER 171809 ISTOTELE PER 87073103 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE e IGNACIO REGISTRATION EXPIRESVIN Check N Permanent AIPIIXLP 2 Parked Motor Vehicle 3 Working Vehicle 1 HSTV98 FL CITATION NUMBER 12/31/2017 Registaton ❑ 1GTO1REG7GZ308795 HI�rW Run 1 YEAR MAKE MODEL STYLE COLOR DAMAGE: 1 Disabling 4 Minor 4 ❑ EST. AMOUNT 2 Yea 2018 GMe SIERRA TK WHRE-WHI 3None cral 88 Unknown $250,00 BB Unknown INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed clue to Damage: i VEHICLE REMOVED BY 1. Rotation 3.D nor Raquel BERKSHIRE HATHAWAY SPEC 255357 t No 2Yea DRIVER 4 Other, Explain In Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) CURRENTADDRESS CITYSTATE ZIP PALM BEACH 15229. CONGRESS AVE. LAKE WORTH FL 33461 Tredx LICEN8ENU118ER STATE REGISTRATION EXPIRES Check 0 Permanent VIN YEAR MAKE LENGTH AXLES One: I Registration ❑ I-"- LICENSENUMBER STATE REGISTRATION EXPIRES Check N Permanent NN YEAR MAKE LENGTH AXLES Two: I Regissaeon ❑ VEHICLE N S E W OR -Road Unknown ON STREET, ROAD, HIGHWAY AT EST. SPEED POSTED SPEED TOTAL LANES TRAVELING O ❑ ❑ ❑ ❑ ❑ 1300 BLOCK N. OCEAN BLVD. 25 35 2 MAT. RELEASED 1 No HAZ MAT. PLACARD 1 No NUMBER CLASS Area of initial impar most Damaged Area 03 03 2Yea Be Unknown ❑ 2 Yea 88 UnWrown ❑ 2 3 4 15 5 6 7 18 Umlercarriape to #14 5 6 7 19 Overturn 19 6 17 B 16 17 B 20 Windshield 20 MOTOR CARRIER NAME US DOT NUMBER 14 21 Trailer 21 S 13 12 11 10 11 D MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER Vehicle Body Type 15 Law Speed Vehicle Trafiicway Commercial Motor Vehicle Configuration ❑ 16 (Sport) Utility Vehicle 19 1 Tw Way, Not DWkfed 1 Vehicle 10,1X0 m, or less Placarded 8 Tmctorfrriple 1 for Hazardous Materiels 9 Tank more than 10.1)(34) lbs to SM 17 Cargo Ven (t0,0001ba as) (4,538or Not Divided. wino a ❑ 2T Continuous Continuous Left Tum Lena 2 Single -Unit Track (2 -axle and GVWR kg), Cannot Classify Coach 1 Passenger Car 18 Motor Coad) 3Tvo-Way. Unprotected! more than 10,0001Ds(4,5W kg)) 10 SusILelge van (mats for 9-15 mW;)Me 2 Passenger Ven 19 Other UphlTmcW 110,000 his (peime0 >4 feet)Metllen 351nple4/nll Truck (3ormae exles) occupants, Ntlutlln9 driver) 3 Pickup (4,536 kg) or less) 4 Tvm-Way, DivWeQ Positive 4 Truck Pulling Trident) 11 Bus (seats for more then 15 7 Motor Home 20 Mediumnic avy Trucks (mae Madsen Bummer 5 Tuck Tractor (bobtall) occupants, Including driver) B Bus Nen10,0D0lba(4,538kg)) 5On>Way Tmffcway 8Truck TmctodSemi-Treiler T7 Other, Explain In Narrative 2YU 11 Motorcycle 21 Fan Labor Vehicle 88 Unknown 7 Truck TractodDouble Trrtlk 88 Unknown 12 Moyyed 77 Other, Explain In Narrative Trailer Tyles 1 Single Semi Trader 8 Pole Trailer 13 11 Terrain Vehicle (ATV) 88 Unknown 2 Tandem Send Trailer 9Towed Vehicle Cargo Body Type CommlNon-Commercial TRAILER TRAILER 3TWkTmMr 13 intermodal IOAub Transport 1 Intemiate Carder 3 Van/Enclosed Box Container Chassis 5 Boat Trailer Narrative 4 Hopper 14 Valine Towing ❑ ❑ 4 Saddle MounVTreiler 77 Other, Explain in ❑ ateCo Carder ❑ B Utility Troller 85 UdMbwn AnaNer Vehicle 3 Not In CommencelGove 3 loam 7 Hausa Trailer 6Cargo Tank B Cargo Tank 1 No Carpo It 4 Not N Commema/ONer Truck Truck 7 Flatbed (vehicle 10.000 Its 2 Bus (vehi 10.00 Most Harmful Event Non4:uTtolon 1 10.0010 lbs (4,538 Comm kB) or leas B Dump (4,536 kg) or leas not 10renover 210,D01.28,0001be 4536-11,783k 9Concrete Mixer displayingHM GVWR/GCWR 4 lord 2 Fire/Explosion 3 More than 28,000 Ica (11,791 10Aulo Transport 77 Other. Explain 3lmmemian mersi 4 Not Applicable 11 Garbage/Refuse Narrative 4 JeckknRe Collision with Non -Fixed Object 14 5 Cargo/Equipment Loss w Shift10 Federman Collision Fixed Object 12 Lop BB Unknown 29 Cable Barrier Emergency 191mpact AftenuatodCresh 6 Fell/Jumped From Motor Vehicle 11 PetlaioyUe Cushion 30 Concrete Traffic Benner Vehicle Use 7 Thrown or Felling Object 12 Railway Venda ("in, engine) 20 Bridge Overread Structure 31 Other Traffic Banner Sequence of Events 8 Ren Into Water/Canel 9 Order Non -Callison 13 Animal 14 Motor VehiUa In Trans Transport e Fier or Supp 21 Support32Tree (standing) 22 Bntlpe Rail 33 P hl Support 1 td 2M 15 Perked MotorVerde34 [4046 Sequence of Events only) ig yyom Zone/Melntenerrce 23 CUIVM Sign S Traffic Sign Support Traffic 24 Curb 35 TmRmc Signal Support 1 No 14 45 40 equipment Failure (blown tire, Equipment 25 Ditch 36 Other Post, Pole, or Support 2 Yea brake tedium, ed.) 17 Stack By Felling, Shning Cargo or 26 Embankment 37 FMca 41 Separation of Units Anything Set in Motion by Motor 27 Guardrail Fete 38 Mailbox 88 Unknown 4th 42 Ran OR Roadway, Right Vehicle 28 Guardrail End 39 Order Fixed Object (wall, ❑ 43 Ran OR Roadway, Left 18 Order Nan -Fixed Old build tunnel etc 44 Crom Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Down Ce Runaway Roadway Grade 48 Cross Cl Runaway 1 Straight AheLeft 13 Sopped In Traffic toppe 3 Turning Left 14 Slowing This Vehicle ❑ ❑ I Level 2 Hillcrest ❑ 4 Backing 15 Negotiating a Curve 11 5 Tuning Right 16 Leaving Traffic Lane 77 B Flashing Signal 7 Nana 9 Rahway Crossing Roadway Alignment 1No Console 2Brakes 13 Wheals 1 3 Uphill 6 Changing Lanes 17 Entering Tmfic Lane Device 4 School Zone Sigh 3 Time 14 Windows/ 4 Downhill 1 Straight 1 5 Seg (bottom) 2 Curve Right 8 Parked 77 Order, Explain in Narrative 10 Meting U -Tum 88 Unknown 10 Person (including Device 4 Lights (head, Windsheld Flagman, Officer, 3 Curve Len 11 OvertaM esti 5 TrafficControl Guard, etcJ signal, n 15 Minora Signalla Staining 18 Truck Coupling 77 Order, Explain In Spacial Function ilio Special FUan 9Ambuleca n141ntamJry Bus BStap Sign 7Wpam Trader HdtlV Narrative 2 Fan Vehicle 1 of Motor Vehicle 10 Fire Truck 15 Cheney?our Bus 7 Yield Sign 9 System Selery Chains Be Unknown 3 Police 1 t Fero Labor Transport 18 Shuttle Bus 10 Body, Doors 77 Order, Explain in Boy, 7 Teri 12 Srhacl Bus 17 Farm Labor Bug 11 Power Train N8 B Military 13 TrensiVCammuter Bus 88 Unknown Unknown 125us erasion BB Unknown VIOLATIONS PERSON# NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER ISTOTELE PER 1 e IGNACIO 316.087512) RIVING ON LEFT Si DE NO PASSING ZONE AIPIIXLP PERSONS NAMEOF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON# NAMEOF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV 90010 S PERSON# 7 Reporting Agency Case Number HSMVCrash Report Number 171809 87073103 1 Driver 2 Nan VEXICLEp NAME PHONE NUMBER hetlttt ❑ -Motorist 7 1 3 Passenger ARISTOTELES IGNACIO PEREZ MARQUEZ (SS7)7291 Driver Re-exam CURRENT ADDRESS (Number and Street) CITY& STATE LP CODE 2541 BOUNDBROOK BLVD APT I IB WEST PALM BEACH FL 33406 DATE OF BIRTH SEX: ❑ Mab 7 DRIVERS LICENSE NUMBER STATE EXPIRES 1N Nona SEVERITY (Ii 2 F9mab 2 2 Fatal within W days) Possible 5 ( 7 ) 1 0713111951 Be Unknown P-625-00957.271-0 FL 07/3112025 3 Nan-mcapedtatlrp B Non -Traffic Fatally DRIVER -1 OLType Required Endorsement• ht Drivers Actions at Time of Crash 3rd Condition At ❑ 1 A 2 8 3 C 1 No Contribution Action 28 Ran op Roadway Time of 1 4 DA7hau8eur 1 Yea 19 2 Operated MV In Carelss or 27 Disregarded other Trema 1:1Crash 5 EADperetor 2 N Negligent Manner Sign 5 E/Oper-Real 3 No Req. Endorsement 3 Felled to Yield RlBht-of-Way 28 Disregarded Other Road 1 Apparently Normal 7Nane 4Improper Backing Markings 3 Asleep or Febuged B Improper Tum 29 Over-ComictingtOver 5111(akk) or Fainted Driver Distracted By 4 Omer Inside the Vehicle St"MB 5 Selcure, Epilespsy, Blackout (explain In real 2nd Followed too Closely 7 Physically Impaired 1 Not Distracted (explain External Distraction 11 11 Ren Red Light W Swerved Avoked Due B Emotional (depression, or Devi camk C hone, ecalion (outside he vehicle, explain ❑ 12 Drove too Feet for Conditions 4th angry, disturbed, am, Devices (cell phone, etc. 1 b Wlrld, Slippery Sutlers, MV in sanative) 13 Ren S Sign ❑ B Urltlx he In9uarxs of 3 Other Ebdmnk Device Non-Matalst In Roadway, etc. M o MDain 81matte 17 er Posted mol (navigation tlevica, DVD player) 77 Other. in Exceeded Posted Explain in Nartauve 17 Exceeded 31 Open In 31 Operated Unknown SS Unknown 21 Wrong Side or Wrong Wey Reckless orAgreeasive Manner 88 Unknown N Unknown a Wrong W gr sive M DRIVER VISION OBSTRUCTIONS 25 Failed to Keep In Proper Lana 77 Otter Contributing Action 1 Maks Not Obsoured 5 Load on VehnJe 9 Smoke 21nch ment Weather 8 BulldinglFixed Object 10 Glare 7 DRIVER OR PASSENGER 3 PerkediSlopped Vehicle 751gnslBiilboartla 77 All Omer, Explain 4 Treins/Crops/Bushes 0Fog In Nonair Helmet Use (HU) Eye Protection( EP) Restraint Systems DRIVER OR PASSENGER ❑ 1 DOT -Compliant 1 yes 3 IRS) Motor Vehicle SeatingPosition: LOCATION: SEAT ROW OTHER Motorcycle Helmet 2 No ❑ 2Oher Helmet 3Not Applicable 1 Not Applimble(ncn-malmist) Sent Row Other (LOC) 1 7 1 3No Helmet 2None Used- Motor Vehicle Occupant 3 Shoulder and Lep Beat Used 1 Leh INot APPlicable 1Front 4 Shoulder Beat Only Used 2 Mlode 2 Sleeper Section of Truck Cab Air Bag Deploy" 5 Lep Belt Only Used 7 3 Right 2 Second 5 Deployed -Omer 3 Other Enclosed Cargo Area Elxtlon (EJECT) knee, air bell ek. 8 Restraint Uaatl -Type Unknown 77 Other 3Third 1Not Elected ❑ ( ) 4UnenWSed Cargo Ante 1Not Apprceble BDapbyetl- 7ChIHRestraint System - Fomard Femp in Fourth 2 (explain 4 ❑ 2 EladeQ Totally 2 Not Deployed 8 Child Restraint System Fad 5 Trolling Unit 1 Combination Y � narrative) 77 OMer Row 3 EjadaQ 3 De b d ran) 9 Booster Seat 88 Unix— 6 Riding on Motor Vehicle Exterior (non- Pantally p y 7 Deployee-Curtain SB Unknown 4 D 10 Child Rxaalnl � Willing unit) 4 Nol Applicable oyon$ka Be nYmxl T7 Other. Explain InYNertatl epe 88 Unknown 88 Unknown erlat Description 1P gff;,an F-12 Non-Metorlst Lxeon tlAt Time of Crash B Sidewalk Aetlon Prior to Crash ❑ 1 Intersection - Marked Crosswalk Island 5 WalHng/Cycllrp on Sidewalk 11lk B MedlaNCrossin Omer Pedestrian (whesltlperl, penton in e building, skater, Pedestrian conveyance, etc 2 lntersecton - Unmarked Crosswalk g 10 Driveway Access B In Roadway —Other (working, 3 3lntersneon - Oher4 Midblock- Marked Crosswalk 11 Shared -Use Path or Trail 1 Crossing Roadway OtherBicyclist Cyclist 4 12 Roedwey 7Adjplaying,c nt to aY (e.g,, La- Marked Cmuwalk to Other, Motor Vehicle Not in Tres Transport 50rked,a Travel STravel Explain In Narnsi 3Walkig/CCmes her Location 77 Along shoulder, Median) Roadway ek 8 Lane 8 Going la or from Scholl (K-12) Lane ae Unknown with Traffic 5 Occup SOm+panl ofe Non-MotorVehitle smiBicycle 7ahqukerlRoedsida adjjaja�tYhotravel lenel 9 Working In Trehoway Transportation Device NorhAlotorlot Adtichrolulnuumatence, 4 WelkinglCycling Along (Incident response) 10 None 7 Unknown Type of Non -Motorist❑ 1No Improper Ashen Roadway Agelnst Tramc (In Lt 2 DanlOesh or adjacent to travel lane) 77 Other, Explain In Narrative 3 Failure to Yield Righbf-Way 88 Unknown 4 Failure to Obey Trait Signs 7 None Safety Equipment 5 Lighting 2 Hearst BNot Applicable Protective Pads Used Signals, or Officer 7 Entering/ExWng Perked5tandng 10 Improper Tum/Merge erne 51n Roadway Vehicle 11 Improper Passing ❑ 77 Other, Explain (elbows, knees, shins, etc.) In Narrative (Me Improperlynding, lying, wondllg, playing) 8lnatlereve (talking, selling, ek) 12 Wrong -Way Riding orWalldrig 4 Reflective Clothing packet SB Unknown Nan 8 Dowl Valli Related (workirig B Not Visible (dark doming, no 77 Other, Explain n ative backpack, etc) on, pushing, leevinglapprosching) lighting, etc) 88 Unknown ALCOHOtJORUGIEMS SUSPECTED ALCOHOLTESTED: ALCOHOL TEST TYPE:[ALCOHOL BAC SUSPECTED DRUGTESTED: DRUG TEST TYPE:DRUG TEST RESULTULT : No ALCOMOLUSE: ❑ vem Teat ❑ Briefth ❑2COMPLETED❑ OysGUSE: 1 188 Test Not Give I Blood 2 Yes lenITIMNoliGlon 3Test G2 77 Ohei Explain 3Test Giveen�n❑770mx❑ 3P�ng2 12 as Unlmam BB Unkilown, If Tested In Narrative 98 UNKNOWN Unknown Unkiwwn, XTesled Explain M Narrative Be Unkilown SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME GRID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1Not EMS 311 -ase Er ❑ 2EM8 3Law Enhxcament 7 77 Other, Explain In Narrative !re Unknown ADDITIONAL PASSENGERS PERSON%VEHICLE% ME OATEOFBIRTH INJ SEX I LOC:S I R O EJECT HU EP ASD RS CURRENT ADDRESS (Number and Street, CITY I STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO t res n..wu s ew a use ura.v n oe,., e.vn w 11nMYLYYaan ❑ PERSON% VEHICLE% ME DATEOF BIRTH INJ I SEX I LOC:S I R 0 EJECT HU EP I ABO I RS CURRENT ADDRESS (Number and Smal CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR IO EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO t era n..s.m s rw s u. oa<...v n m., sewn n NniwY LLYan ❑ HSMV 90010 S NARRATIVE Reponing Agency Can Number HSMV Crash Repan Number CHARGE 171809 87073103 Vehicle 2(Golf Carl) was driving northbound on SR (A1A) North Ocean Blvd. As Vehicle 2 approached the 1300 block of SR (A1A) North Ocean Blvd, the driver slowed down, applied his left tum signal and slopped in preparation to make a left hand tum. Vehicle 1 was driving northbound behind Vehicle 2 and the witness was driving behind Vehicle 1. The driver of Vehicle 1 attempted to pass on a double solid line as Vehicle 2 began to make his left hand tum. Vehicle 1 struck Vehicle 2 in the left rear quarter panel causing minor damage. This Impact caused minor damage to Vehicle 1 also. Both vehicles drove off SR (A1A) to the left onto the road shoulder. The witness was interviewed and verified the accident as stated by the driver of Vehicle 2. ADDITIONAL PASSENGERS PERSONA VEHICLE% AME DATE OF BIRTH INJ SEX LOC: R O EJECT HU EP ABD RS 3 1 RONALD EIERR LOUIS 1/26/1976 1 I 1 I 3 1 1 1 2 3 CURRENT ADDRESS(Number and Street) CRY STATE ZIP CODE MSWMSTST. RIVIERA BEACH I FL 30464 SOURCE OF TRANSPORT TO MEDICAL FACILITY SOURCEOF TRANSPORTTOEDICALF EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO i xmn..rurs... PERSON % VEHICLE % AME ATE OF BIRTH INJ SEX LOC:S R 0 EJECT HU EP ASO RB 4 2 JOSEPH PEPIN 1 I 1 I 1 1 1 1 I 2 5 CURRENTADDRESS(Numberand StmQ CITY STATE ZIPCODE 395 LAFAYETTE RD. HAMPTON NH 03842 SOURCE OFTRANSPORTTO MEDICAL FACILITY EMS RUN NUMBER MEDICAL FACILRY TRANSPORTED TO � xan..e.aa� ewe u. nwe.r.�non., Gm.nn ZIEMSAGENCYNAMEORID rur,.rws.. ADDITIONAL VIOLATIONS PERSONA 1 NAMEOF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON% NAMEOF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER IDBADGE% RANK OFFICER NAME DEPARTMENTTYPEOFOEPT. 755 OFC. R. WILSON GULF STREAM POLICE DEPARTM POUCEOEPARTMENT PD1 HSMV 900105 4 B Page -01- REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER DIAGRAM 171809 1 87073103 HSMV soon S No Diagram Required HSMV soon S VEHICLE # 2 Check if Commercial ❑ 7718�09^Bnc"8N1Y"no" H870731 h sport Number 1 Vehicle In Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES VIN 2 Parked Motor Vehicle 1 Check N Pormenent 3 Working Vehicle JC980C FL 0 210 212 01 9 Registration ❑ FLAS7815 Hit add Run YEAR MAKE MODEL STYLE COLOR DAMAGE: EST. AMOUNT 1 No 1 1 DleaNinp 4 Minor 8SUnkncwn 2013 ASPT BP BLUE -BLV 3 nnctlanel 88 Unknown E $100.00 INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Toaed due VEHICLE REMOVED BY 1. Rotation FED. INSURANCE CO. to Damage: 1 2. Owner Request 1114333544-07783 7Na 2Yea DRIVER 4: Other Explain In Narrative El NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ CURRENTADDRESS CITY & STATE ZIP VALLUM BINNIE 1314 N. MEAN BLVD. GULFSTREAM FL 33483 T-1- LICENSE NUMBER STATE I REGISTRATION EXPIRES Check NPennanent VIN YEAR MAKE LENGTH AXLES One: Registration ❑ Trailer LICENSENUMBER STATE I REGISTRATION EXPIRES Check N Permanent VIN YEAR MAKE LENGTH AXLES Two: Registration ❑ VEHICLE N S E W Off -Road Unknown ON STREET. ROAD, HIGHWAY AT EST. SPEED POSTEDSPEED TOTAL LANES TRAVELING 211 ❑ ❑ ❑ ❑ 1300 BLOCK N. OCEAN BLVD. 5 35 2 MAT, RELEASED HAZ MAT. PLACARD NUMBER CI.A55 Area cd Initial Impar Most Damapetl Area 1No ❑ 7Na ❑ 10 10 2 Vae 2 Vee 2 3 4 5 6 7 18 Undercarriage 18 2 3 4 5 6 7 88 UnWto ri 88 Unk ov rl 1 15 16 17 8 19 Overturn t9 7 15 16 17 B MOTOR CARRIER NAME US DOT NUMBER i4 g 20 Windshield 20 13 1211 0 21 Trainer 21 14 13 1211 0 9 MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER Vehicle Body Type 15 Low Speed Vehicle Tratflcway, Non-0olllabn Commemlal Motor Vehicle Configuration 77 18 (Spon) UNity Venule 17 Cargo Van (10,000 Ica 2 Fire/Explosion 3 Tumhg LM 1 Two -Way, Not DNitlatl 2 Two -Way, Not Divided, a 14 1 Vehicle 10,000 Its or less Placarded for Hazamaua Materials B Tmaorrrripe 9 Truck rtwre man 10,001) lbs (4,538 8 Fell/Jumped From Motor Vehicle (4,536 kg) or leas) 7 Thro m or Felling Object Sequence of Events with Contlnuous LM Tum Lane ❑ 2 Singlo-Un4Tmrk (2ada end GVWR top), Cannot Classify 7 Passenger Car 7B Motor Coach 40 equipment Failure (blown aro, We 31No-Way, Divided, Unpmlecte: deka fallum, etc) more men 10,000 lbs (4,536 kg)) 10 BUS/Large van (sears for 9-15 2 Passenger Van 19 Omer Ught Tracks (10,0001bs (pfeet) Median 44 Cmsa Metlian 3 Single -Unit Truk (3 or more axles) occupants, Including drv9r) 3 Pickup (4,538 kg) ar lase) 4lNv-Way, Divided, Poslave of Motor Vehicle 2 Farm Vehicle 4 Truck Pulling Tra lerls) 77 Bun (seats for more men 15 ]Molar Home 20 MedlumMee Tnuka mora vY ( Median Bather Nenalve STreclr Tmctw (bobtail) 5 amPand, Including driver) 9 Bus man 10,0001bs (4,538 kg)) 5 One -Way Tmffieaay 13 TmnaH/Commuter Bus Truck Trector/Seml-Treller 77 Other, Explain In Narrative 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 7 Truck Tmutor/Double Truck BB Unknown 72 Moped n Other, Explain m Narrative Trailer Type 13 AN main Vehicle (ATV) 88 Unknown 1 Single Semi Trailer 8 pole Trailer 2 Tandem Semi Trailer 9 Toon cl Vehicle Cargo Body Type Comm/Non-Commercial TRAILERI TRAILER2 3Tank Tmiler 10Auto Transpon 13 Intermodal 1 IntemMle Cartier ❑ ❑ 4 Saddle Mountrrmiler 5 Boat Trader 77 Omer, Explain In Narrative ❑ 3 VarvEnclosnd Box Consider Chassis 4 Hopper 14 Vehicle Towing ❑ 2 Not in to Carrier 3 Not in Cammerce/Govammant 8 UOltly Trader Be UnMown 5 Pole-Tmibr Anomer Vehicle 4 Not m Commerce/Other Truck Most Handful Event Non-0olllabn 1 Straight Ahead 1 OvemadvRollover (4,536 kg) or leas not 2 Fire/Explosion 3 Tumhg LM 3 Immersion 14 4 Jackknse 5 Cargo/Equipment Lase or Shift Bedding 8 Fell/Jumped From Motor Vehicle 7 u P�sl 7 Thro m or Felling Object Sequence of Events 8 Ran Into WatardCanal 23 Culvert 90her Non -Collision net 2M [1048 Sequence of Events only[ 14 43 40 equipment Failure (blown aro, 1 Stmight deka fallum, etc) 4d41 Separation of Units Ran OB Roadway, Right F—]42 43 Ran Ort Roadway, LM 7Wpere 44 Cmsa Metlian Comm 110,000 IN, (4,538 kg) or less GVWRIGCWR 210,001-28,0001bs(4,538-11,7831kg) 3 Mom than 26,DD01bs (I1,793kg) Collision with Non -Fixed Object 10 Pedestrian 11 Pedalcycle 12 RalWay Vehicle (tram, engine) 13 Animal 14 Malar Verich In Transport 15 Parked Motor Vehicle 18 Work ZonduMehtenance Equipment 17 Struck By Felling, Shifting Cargo w Anything Set In Motion by Motor Vehicle 1 No Cargo 8 Cargo Tank 15 Not Applicable 45 Crass Constants 1 Straight Ahead Roadway Grade (4,536 kg) or leas not 46 Dovnlhill Runaway 3 Tumhg LM 10 Auto Transport T7 Other, Explain in 11 Garbage/Refuse Bedding 22 Bridge Reil 7 u P�sl Roadway Alignment 1 ED 23 Culvert 33 Utility Pole/Lght Support B rrp Lanes ❑ 4 Downhill 15 Minora 1 Stmight B Parked 5 Seg (bottom) 16 TruckCoupling 2 Curve Right 10 Making U -Tum 7Wpere 25 Died 3 Curve Lea 11 Overtak as. Special Function 1 No Spacial Function 9 Ambulance g y s eskxwm of Motor Vehicle 2 Farm Vehicle F 10 Truck BBte 28 Guardma Eric 39 Other Fixed Object (well, 11 Farm Labor Transport Nenalve 71" Taxl 12 School Boa 8 Military 13 TmnaH/Commuter Bus 1 No Cargo 8 Cargo Tank 15 Not Applicable 2 Bus 7 Raked (vehicle 10,ODD Ins B Dump (4,536 kg) or leas not 9 Concrete Mixer displaying HM piawm 10 Auto Transport T7 Other, Explain in 11 Garbage/Refuse Narrative 13 Stopped In Traffic 14 Slaving 15 Negotiating a Curve 16 Leaving Traffic Lane 17 Entering Traffic Lane T7 Other, Explain In Narrative 88 Unknwm 14 Intercity Bus 15 Chanernour Bus 16 Shuttle Bus 17 Farm Labor Bus Be Unknown Vehicle 1 19 Impact Attenuetw/Crash Cushion 29 Cable Ramer Emergency 20 Bridge Overhead Sbuclum 30 Concrete TmfBc Bather Vehicle Use 21 Bridge Pier or Support 31 Other Traffic Ramer 13 Wheels 22 Bridge Reil 32 Time (standing) ns Wshield 1 10 Person (including 23 Culvert 33 Utility Pole/Lght Support 5 Tremc Controllaman ❑ signal, Mil) 15 Minora 34 Traffic Sign Support Guam, etc.) B Steering 16 TruckCoupling 24 Cum 35 Tmffic Signal Support 7Wpere 25 Died 36 Other Post Pole, or Support 1 No 26 Embankment 37 Fence g y s eskxwm 27 Guardrail Fe W Mailbox BBte 28 Guardma Eric 39 Other Fixed Object (well, 11 Powm Tmin 13 Stopped In Traffic 14 Slaving 15 Negotiating a Curve 16 Leaving Traffic Lane 17 Entering Traffic Lane T7 Other, Explain In Narrative 88 Unknwm 14 Intercity Bus 15 Chanernour Bus 16 Shuttle Bus 17 Farm Labor Bus Be Unknown PERSON# Vehicle 1 CHARGE ❑Thisshing Signal 7 None FL STATUTE NUMBER Controls 9RF8tweYCreaalrg 3 Brakes 13 Wheels 4 Sc Device 4 School Zana SI9N 3 Tires ns Wshield Device 10 Person (including 4 Lights (heed, Windshield Wmdehkltl 5 Tremc Controllaman Flagman, BKer, O signal, Mil) 15 Minora Signal Guam, etc.) B Steering 16 TruckCoupling B Stop Sign 77 OmerExplain In 7Wpere Trailer Hit 7 Yield Sign Narrative, 9 Exhaust System Safety Chains BB Unknam 10 Body, Doore 77 Omer, Explain in 11 Powm Tmin Nenalve PERSON# NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON# NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON# NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV 90010S 6 a NARRATIVE NAME OF VIOLATOR FL STATUTE NUMBER RepoNng Agency Case Number CITATION NUMBER PERSONA HSMV Crash Report Number FL STATUTE NUMBER CHARGE CITATION NUMBER 171809 (PD) 87073103 ADDITIONAL PASSENGERS PERSONA VEHICLEp AME DATE OF BIRTH INJ SEX LOGS R 0 EJECT HU EP ABO RS 5 2 JOY SCHUPPERT 1 I 2 I 1 I 2 1 1 5 I CURRENTADDRESS(Numberand SVeel) CITY STATE ZIP CODE 45 DAME RD. NEWMARKET NH 03857 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMSAGENCYNAMEORID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO inert I EM]]Yn lnhmnlTN�,EWw•n 1 PERSON pAME DATE OF BIRTH INJ SEX LOC'. S R O EJECT HU EP ABD RS ]VEHICLE 6 2 ANGELA NICOU 1 2 3 2 1 1 5 CURRENT ADDRESS (Number and SVeel) CITY STATE ZIP CODE 30 KENDALL PARD RD. INS DERRY NH 03808 TRANSPORT SOURCE OF TRANSPORT TO MEDICAL FACILITY TO MEDICAL EMSAGENCYNAMEORID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO SOUR 1 ❑ ADDITIONAL VIOLATIONS PERSONA NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSONA NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER IOIBADGEa RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. 755 C. R. WILSON GULF STREAM POLICE DEPARTM POLICE DEPARTMENT (PD) HSMV 90010 S PERSON # 2 RGPWft Agency Case Number HSMV crap, Report Number 171809 87073103 1 Driver Non-Motorist VEHICLE# NAME PHONENUMBER Checltk ❑ 2 1 2 Remnmend 3 Passenger OAVW SCHUPPERT (603)8]4ie7] Driver Reexam CURRENT ADDRESS (Number arta Street)CITYB STATE ZIP CODE 45 DAME RD NEWMARKET NH 03667 DATE OF BIRTH SEX: I Male DRIVERS LICENSE NUMBER STATE EXPIRES INJURY 1 SEVERITY (INJ)41 eclbtl ng None 2 Female 2 Possible 5 Feleal (within 30 clays)El 02/0611964 as unknown 02STD64061 NH 02/0611922 3 Non4ncapactating 6Non-Tnsmc Felatiy DRIVER I4030 Raqulntl Endorsements tat 1 No Contribution Allan Actions at 28 Ren o8 Rof oadway ]b Timelorna 4 D/ChauBeur 3 1 Yes 2 Operated MV In Consist or 27 Disregarded otherTnmc ❑ Crash 5 E/Operator 2 No Negligent Manner Sign 6 E/Oper-Rest 3 No Req. Endorsement 3 Failed k Yield Rightaf-Way 28 Disregarded Omer Road 1 Apparently Normal 7 None 4 Improper Bacleng Markings 3 Asleep or Faguged Driver distracted By 6lmproperTum 29 OvinCanacting/Over 5 In 65(elurk)orF anted 4 Omer Inside the Vehicle Stearinp Y, Blackout (explain In namative) 10 Followed Ica Closely 7 Physically Impaired 5 External Connection 2nd 11 Ran Red Ughl 8 Emotional (deposition, 1 Not Donis Swerved orA : Due Co 4th angry, 2 Electronic Communication to MV, rid disturbed, In u arc) the vahide, explain 12 Drove too Fest for Conditions to Wino, Slippery Surfs Devices (cell one, etc. Ph 9 Under me Ineu of In narrative) In narrative) 13 Ren Stop Sign Object. Non-Mabtlst In 30merist In Electronic siAl 6Texting 15Improper Penpnp Roadwa, ek. MedicetlenpDMpslAlmhol ❑ n deviceDevice (navigation device, DVD player) 7 Inattentive 17 Exceeded Posted Speed 3/ Operated MV In Emetic, 77 Omer, Explain In Narrative N Unknown 21 Wrong Side of Wmng Way Reckless erAgnseaaNe Mannar 88 Unknown DRIVER VISION OBSTRUCTIONS ZS led to Keep in Proper Lane 77 Other Contributing Alvan 1 Vision NotObxvred 5 Load on Vsh ce 9 Smoke 2 Inclement Weather 6 SuiMingrFixetl Object 10 Glare DRIVER OR PASSENGER 1 3 Parked/Stoppel Vehicle 7 Slgns/Bilocaks 77 A11 omen, Explain 4 TreeslCrops/Bushe6 e Fop In Narrative Helmet Use (HU) Eye Protection (EP) IRS) ret Systema DRIVER OR PASSENGER ❑ t DOT-Compliant 1 Yes 6 IRS) SEAT ROW OTHER Motorcycle Helmet 2N ❑ Motor Vehicle Seating Position: LOCATION: 20mer Helmet 3Not Applicable 1 Nat Applkabh(nonmtonsl) Seat Row Other (LOC) 1 1 1 3 No Helmet 2 None Used - Motor Vehicle Occupant 3 Shoulder and Lap Balt Used 1 Lek 1 Not Ikabb 1 Front APP 4 Shoulder Bell Only Used 2 Middle 2 Sleeper Section of Truck Cab Air Bag Deployed 5 Le Belt Only Used 2 Second p 5 Deployed-Mar P Y 3 Right 3 Other Enclosed Carpo Area Ejection (EJECT) 6 Restraint Used -Type Unknown 3 Third (knee, lois belt, etc.)7 (e Other 1 Not E ea Child Restraint (explain In 4FOuFacing 6 Deployed.Combination rth 4Unencbsed Cargo Area ❑ 2Ejectetl Totally pNat Deployed Y°nr-Rear Feorlp 5Trailing Unit 1 B Child Restraint System Rolwaking narrative) 77 Opfer Row 3Ejected 3Deloed--yFmnt 7Deplcatlon 9Booster Seal 88 Unit-- 6 Riding on Motor Vehicle Extador (con- Partially P Y 7 sin BB Unknown heilling unit 4NotA 4DaPloyatlSide as Deployment Unknown Restraint Typerative oymeM 77 Other, Applicable 77 Omer Erpleln Unknown In Narrative Unknown BB Unknown 00 Unknown .M orl ❑20theraPAedenna n(wheeltlreri, at Location At Time Groh 9Mediank ❑Aetlan Priv to Lneh5 Sidewalk 9 Metllen2roasing Ielelk S y Siworkin person in° building, skater. Pedestrian conveyance, pcIntereascionOthers -O he 2 lntenectlanortUnmelCrsrked swalk lid/InRoadw 10 Driveway Access In Ro°daaY—Omer g. Crosswalk 11 Shared-Use or 1Crossing WaN^0. ek.) YrJ 40meriC of 4Mldblcck-Markedd CrossMidw°Il-Merketl AreaTrall 12 Nan Trakiavaam Cross 7 Adjacent to Rakdway(e.g., 2 Waiting k Cross Roadway 5 Occupant of Motor Vehicle Not In Transport 5 Travel Lane - Other Location 77 Omer. Explainy shoulder, median) In Narrative Roadway Abin et cup 6 Bicycle Lane BB Unknown Roadway with TnsiticeIna 8 Going to or from School (K-12) Win Trg 8 8 Occupant of a Nan-Mohr Vehicle nto 7 shoulder/Roadside 9 Working in Tralkuwey to bevel lane) Device 4 Wallai (Incident response) en-ooe one Hume ansae 4oadwayAgainst Aidrp 7 Unknown Type of Nan-MWanat 7 Unknown Ty 1Na ImproprlDash rAetion Roadway (in 10 None In ❑ t to "t etlaTraffic or 77 Other, Explain In Namative 2 Can/Desh or adjacent to bevel lana) Way 88 Unknown 3 Failure to YieldObey 4 O TralSe Spns Traft Signs 1 None B.hry EgWpment 5 App NotLig 2 Helmp 8 Not Applicable 3 Prolective Peds Used gna13, r ❑ Slpnab, or ORIcar 7 EntetlnglExitlnp PeAedlSbndlirrp 101mproperTumRaerye ecu Nm 5 In Roadway Vehicle 11 Improper Passing 77 Osler, Explain a, knees, shim, air) In Nametive Improperly (standing, lying, working, playing) 8Inattentive (talking, eating, at) 12 Wrong-Way Riding or Walking 4 Refl 4 (jacket, 00 Unknown ❑ 8 Disabled Vehicle Related (waking 9 Not alible (dark clothing, no 77 Other, Explain in Narrative backpack, betl�eck, etc.) OM) on, Pushing, leaving/approeNng) lighting, etc) 88 Unkrwml ALCOHOL/DRUGIEMS SUSPECTED ALCOHOLTESTEO: ALCOHOL TEST TYPE: LCOHOL BAC USPRUGEU EDBE DRUT. G TESTED: CRUG TEST TYPE:DRUG TEST RESULT' : I No1❑ I Test Not Test I Blood 2 Breach ❑ BUILT ❑ ❑ DYes ❑ I. G W an Positive ❑. 2 YesALCO 2 Yes t Given 3TesOf 77 Other,Explain COMPLETED T7 Other,3 Pending Unknown 88 7 Narrative 68 UNKNOWN Unlmown 88 Unknown,GHTe� N e r SOURCE OF TRANSPORTTO MEDICAL FACILITY EMS AGENCY NAME OR IO EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 NotTransporte0 2EMS 3Lmw Enforcement 1 77 Omer, Explain in Narrative 88 Unknown ADDDIONAL PASSENGERS PERSON# VEHICLE# AME DATE OF BIRTH I INJ I SEX I LOC:S I R O 1 EJECT I HU EP I ABD RS CURRENT ADDRESS (Number and Street) CITY I STATE ZJP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY❑ EMS AGENCY NAME OR IO EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO ir.mn. uma°n'�°,r tonna.,. ex.sMnoe..ertne PERSON%VEHICLE# AME DATE OF BIRTH I [NJ I SEX I LOC'S I R O 1 EJECT I HU EP I ABD I RS CURRENTADDRESS(Numberand Strap) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO r wn.roe..a: rvesi.. em.t rru�.. rsr. w rm�wmu.uo.� HSMV 90010 S S S Page W_