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HomeMy Public PortalAboutPRR 19-2681TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered in person January 10, 2019 Frederic Detwiler (Police Report 161944) Verbal Request for a copy of the Police Report #161944) Frederick Detwiler: The Town of Gulf Stream has received your verbal public records request. The original public records request can be found at the following link: http://www2.gulf-stream.org/weblink/0/doc/121796/Page1.aspx We consider this request closed. Sincerely, Reneé Rowan Basel As requested by Rita Taylor Town Clerk, Custodian of the Records FLORIDA TRAFFIC CRASH REPORT LONG FORM ® SHORT FORM UPDATE ❑ (Shaded Areas) MAIL TO: DEPARTMENT OF HIGHWAY SAFETY & MOTOR VEHICLES TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING TALLAHASSEE, FL 32399-0537 TOTAL # OF VEHICLE SECTION(S) TOTAL # OF PERSON SECTION(S) TOTAL # OF NARRATIVE SECTION(S) CRASH DATE TIME OF CRASH DATE OF REPORT REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 09/25/2016 10:28 AM 09/25/2016 161944 84212026 CRASH IDENTIFIERS COUNTY CODE CIN CODE COUNTY OF CRASH PLACE OR CITY OF CRASH CHECK IF WITHINTIME REPORTED TIME DISPATCHED 06 44 PALM BEACH GULF STREAM CITY LIMITS L 10:28 AM 10:28 AM TIME ON SCENE TIME CLEARED SCENE CHECK IF REASON (if Investigation NOT Complete) Notified By: l Motorist X 2 law Enforcement 10:28 AM 12:45 PM COMPLETED ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAYAT STREET ADDRESS # AT LATITUDE AND LONGITUDE 0 4400 S.R.A1A(N OCEAN BLVD) FEET MILES N S E W X 1:1❑ ❑ AT/ FROM INTERSECTION WITH STREET, ROAD, HIGHWAY © O OR FROM MILEPOST # 50.00 COUNTY RD Road System Identifier 7 Forest Road Type of Shoulder Type of Intersection 5 Traffic circle 1 Paved 2 U.S. 5 Lotal 9 Parking Lot 2 Fou _Way Intersection 7Five-Point, or More ❑ 1 Interstate 4 County 8 Private Roadway ❑ ❑ 1 Not at Intersection 6 Roundabout 2 Unpaved 3 State 6 Turnpike/Toll 77 Other, Explain in 3 T -Intersection 77 Other, Explain in Narrative 2 1 3 Narrative 3 Curb 4 Y- Intersection CRASH INFORMATION (CHECK IF PICTURES TAKEN) Light Condition Weather Condition Roadway Surface Condition School Bus Related Manner of Collisionlimpact 1 Daylight 5 Dark -Not Lighted 4 Fog, Smo Smoke 5 Oil 1 No �/ 4 Slideswi Lighting Freezing Rain 7 Sand Directly Involved 5 Sideswipe, Opposite Direction ❑ 2 Dusk 6Dark-Unknown 1�1 5 Sleet/Hai ❑ 6 Mud, Dirt, Gravel 2 Yes, School Bus pe, Same Direction 3 Dawn 1 77 Other, Explain in 6 Blowing Sand, Soil, 2 8 Water (standing/ 1 3 Yes, School Bus 1 6 Rear to Side 4 Dark -Li hted g 7 Rear to Rear Narrative Dirt moving) Indirectly Involved 1 Front to Rear 88 Unknown 1 Clear 7 Severe Crosswinds 1 Dry 77 Other, Explain 2 Front to Front 77 Other, Explain in Narrative 2 Cloudy 77 Other, Explain in 2 Wet in Narrative3 Angle88 Unknown 3 Rain 4 Ice/Frost Narrative 88 Unknown First Harmful Event Non -Collision Collision Non -Fixed Object Collision with Fixed Object First Harmful Event 1 Overturn/Rollover 10 Pedestrian 19 impact Attenuator/Crash 30 Concrete Traffic Barrier Location 1 On Roadway 2 Fire/Explosion 11 Pedalcycle Cushion 31 Other Traffic Barrier 11 3 Immersion 12 Railway Vehicle (train, 20 Bridge Overhead Structure 32 Tree (standing) 2 Off Roadway 4 Jackknife engine) 21 Bridge Pier or Support 33 Utility Pole/Light Support 3 Shoulder 5 Cargo/Equipment 13 Animal 22 Bridge Rail 34 Traffic Sign Support 4 Median First Harmful Event Loss or Shift 14 Motor Vehicle in Transport 23 Culvert 35 Traffic Signal Support 1 6 Gore within Interchange 6 Fell/Jumped From 15 Parked Motor Vehicle 24 Curb 36 Other Post, Pole or Support 7 Separator Motor Vehicle 16 Work Zone/Maintenance 25 Ditch 37 Fence 1 No 7 Thrown or Falling Equipment 26 Embankment 38 Mailbox 2 Yes Object 17 Struck By Falling, Shifting 27 Guardrail Face 39 Other Fixed Object (wall, 8 In Parking Lane or Zone 9 Outside Right-of-way 10 Roadside 1 88 Unknown 8 Ran into Water/Canal Cargo 28 Guardrail End building, tunnel, etc.) 88 Unknown 9 Other Non -Collision 18 Other Non -Fixed Object 29 Cable Barrier First Harmful Event Relation to Contributing Circumstances: Road Contributing Circumstances: Junction 5 Railway Grade Crossing 10 Road Surface Condition (wet, ❑ El❑ 9 Worn, Travel -Polished Surface icy, Environment 14 Entrance/Exit Ramp 1 15 Crossover - Related snow, slush, etc.) 11 Obstruction in Roadway F1 I El E 1 Non -Junction 16 Shared -Use Path or Trail 2 Intersection 17 Acceleration/Deceleration Lane 1 None 12 Debris 13 Traffic Control Device 4 Work Zone (construction/ Inoperative, Missing or Obscured In 1 None 5 Animal(s) in Roadway 3Intersection-Related 18 Through Roadway 4 Driveway/Alley Access 77 Other, Explain in Narrative maintenance/utility) Non -Highway Work 6 Shoulders (none, low, soft, high) 77 Other, Explain in Narrative 2 Weather Conditions 77 Other, Explain in 3 Physical Obstruction(s) Narrative Related 88 Unknown 7 Rut, Holes, Bumps 88 Unknown 4 Glare 88 Unknown Work Zone Related Crash in Work Zone Type of Work Zone Workers in Work Zone Law Enforcement in 1 No 1 Before the First Work Zone 1 Lane Closure 1 No Work Zone 2 Yes Warning Sign 2 Lane Shift/Crossover 2 Yes 1 No 88 Unknown F]2 ❑ 88 Unknown Advance Warning Area 3 Work on Shoulder or Median 2 Officer Present 3 Transition Area 4 Intermittent or Moving Work 3 law Enforcement Vehicle 4 Activity Area 77 Other, Explain in Narrative Only Present 5 Termination Area WITNESSES NAME ADDRESS CITY & STATE ZIP CODE MICHAEL MADNICK 729 LAKESHORE DR DELRAY BEACH FL 33444 NAME ADDRESS CITY & STATE ZIP CODE NAME ADDRESS CITY & STATE ZIP CODE NON VEHICLE PROPERTY VEHICLE # PERSON # PROPERTY DAMAGE --OTHER THAN VEHICLE EST. AMOUNT OWNER'S NAME ❑ (Check if Business) ADDRESS CITY & STATE ZIP CODE VEHICLE # PERSON # PROPERTY DAMAGE —OTHER THAN VEHICLE EST. AMOUNT OWNER'S NAME (Check if Business) ADDRESS CITY & STATE ZIP CODE J HSMV 90010 S (E) (rev 10/10) Page I of 6 REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 1 161944 84212026 VEHICLE LICENSE!1!!1SrA TE REGISTRATION EXPIRES Check if Permanent VIN 1 V!eheinlTransport3 Pa 1 DCF -4061 I 02/24/2017 Registration 5J6TF2H56CL011279 ing Vehicleehicle Hit and Run YEAR MAKE MODEL STYLE COLOR DAMAGE: EST. AMOUNT 1 No 2 Yes [:� 1 Disabling 4 Minor 2 Functional 88 Unknown 88 Unknown 2012 HONDA CROSSTOUR RO GRY 3 None 1000 INSURANCE COMPANY INSURANCE POLICY NUMBER Towed dueVEHICLE REMOVED BY 1. Rotation to Damage: �4. 2. Owner Request OAKLAND INS. CO. �CWP4103030 1No 2Yes 1 PD 3. Driver 3 Other Ex Iain in Narrative NAME OF VEHICLE OWNER ❑ (Check if Business) CURRENT ADDRESS CITY & STATE ZIP CODE FREDERICK BRADLEY DETWILER 2025 LAVERS CIRCLE APT 401 DELRAY BEACH FL 33445 Trailer # LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES Registration ❑ 1 Trailer # LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES Registration ❑ 2 VEHICLE N S E W Off -Road Unknown ON STREET, ROAD, HIGHWAY AT EST. SPEED POSTED SPEED TOTAL LANES TRAVELING FS.R. WN A1A 4400 BLOCK N OCEAN 35 35 02 HAZ. MAT. RELEASED 1 No HAZ. MAT. PLACARD 1 No HAZ. MAT. NUMBER HAZ. MAT. CLASS Area of Initial Impact Most Damaged Area 2 Yes ❑ 88 Unknown 1 2Yes ❑ 88 Unknown 1 x a � s e � 18 Undercarriage 18 \ ' � s e � Q, +s ,s n e 19 Overturn 19 + +s ,• MOTOR CARRIER NAME US DOT NUMBER 20 Windshield 20 �W. ,] 12 ,1 M • 21 Trailer 21 U n +2 +1 MOTOR CARRIER ADDRESS CITY & STATE ZIP CODE PHONE NUMBER Vehicle Body Type Trafficway Commercial Motor Vehicle Configuration 15 Low Speed Vehicle 1 Two -Way, Not Divided 1 Vehicle 10,000 lbs or less Placarded 87ractor/Triple 2 Two Not Divided, 16 (Sport) Utility Vehicle -Way, with a for Hazardous Materials 9 Truck more than 10,000 lbs (4,536 1 17 Cargo Van (10,000 lbs Continuous Left Turn Lane ❑2 Single -Unit Truck (2 -axle and GVWR kg) Cannot Classify 1 tected (4,536 kg) less) 3 Two -Way, Divided, Unpro Bus/Large for or more than 10,000 lbs (4,536 kg)) 10 Van (seats 9-15 1 Passenger Car 18 Motor Coach (painted >4 feet) Median 3 Single -Unit Truck (3 or more axles) occupants, including driver) 19 Other Light Trucks (10,000 lbs 4 Two -Way, Divided, Positive Median 4 Truck Pullin Trailer(s 11 Bus seats for more than 15 2 Passenger Van 8 (. 3 Pickup (4,536 kg) or less) Barrier 5 Truck Tractor (bobtail occupants, including driver) 20 Medium/Heavy Trucks (more than 5 One -Way Trafficway 6 Truck Tractor/Semi-Trailer 77 Other, Explain in Narrative 7 Motor Home vy p 88 Unknown Trailer Type 7 Truck Tractor/Double Truck 88 Unknown 8 Bus 10,000 lbs (4,536 kg)) 11 Motorcycle 21 Farm Labor Vehicle TRAILER 1 TRAILER 2 1 Single Semi Trailer Cargo Body Type 12 Moped 77 Other, Explain in Narrative 2 Tandem Semi Trailer 8 Pole Trailer 13 Intermodal 13 All Terrain Vehicle (ATV) 88 Unknown ❑ 3 Tank Trailer 9 Towed Vehicle E 3 Van/Enclosed Box Container Chassis 4 Saddle Mount/Trailer 10 Auto Transport 4 Hopper 14 Vehicle Towing Comm/Non-Commercial 5 Boat Trailer 77 Other, Explain in 5 PolrTrailer Another Vehicle 1 Interstate Carrier 6 Utility Trailer Narrative 6 Cargo Tank 15 Not Applicable 88 Unknown 1 No Cargo 7 Flatbed 2 Intrastate Carrier 7 House Trailer lbs 8 Dump ((vehicle) in Commerce/Government 2 P ❑ 3 Not Bus or les 4 Not in Commerce Other Truck[:] 9 Concrete Mixer (4,536kg) or less not / 1 10,000 lbs (4,536 k ) or less displaying HM placard) Comm 210,001-26,0001bs `44,536-11,793 kg) 10 Auto Transport 77 Other, Explain in Most Harmful Event Non -Collision GVWR/GCWR 3 More than 26,000Ibs (11,793 kg) 11 Garbage/Refuse Narrative 1 Overturn/Rollover 4 Not Applicable 12 Log 88 Unknown 2 Fire/Explosion 3 Immersion Collision with Non -Fixed Object Collision Fixed Object 29 Cable Barrier Emergency y 4 Jackknife 10 Pedestrian 30 Concrete Traffic Barrier 11 5 Cargo/Equipment Loss or Shift 11 Pedalc cle 19 Impact Attenuator/Crash Cushion 31 Other Traffic Barrier Vehicle Use y 6 Fell/Jumped From Motor Vehicle 20 Bridge Overhead Structure 12 Railway Vehicle (train, engine) 21 Bridge Pier or Support 32 Tree (standing) Sequence of Events 7 Thrown or Falling Object 13 Animal 33 Utility Pole/Light Support 22 Bridge Rail 8 Ran into Water/ Canal 14 Motor Vehicle in Transport 23 Culvert 34 Traffic Sign Support 9 Other Non -Collision 15 Parked Motor Vehicle 24 Curb 35 Traffic Signal Support 1 Sequence Events 16 Work Zone/Maintenance 36 Other Post, Pole, or Support (40-46 of only] 25 Ditch 1 No 22 40 Equipment Failure (blown tire, Equipment 26 Embankment 37 Fence 2 Yes 4th brake failure, etc.) 17 Struck By Falling, Shifting Cargo or 27 Guardrail Face 38 Mailbox 88 Unknown 3rd 41 Separation of Units Anything Set in Motion by Motor 28 Guardrail End 39 Other Fixed Object (wall, ❑ 42 Ran Off Roadway, Right Vehicle building, tunnel, etc.) 43 Ran Off Roadway, Left 18 Other Non -Fixed Object ❑ 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects ❑ 45 Cross Centerline 1 Straight Ahead 46 Downhill Runaway 13 Stopped in Traffic This Vehicle Roadway Grade [_1 3 Turning Left 14 Slowin4 Backing 15 Ne otiatin a Curve1 Level Roadway Alignment Negotiating 8 Flashing Signal 1 8 5 Turning Right 2 Hillcrest 16 Leaving Traffic Lane 1 12 Suspension 15trai ht 6 Changing Lanes 9 Railway Crossing 3 Uphill g 17 Entering Traffic Lane Device 1 None 13 Wheels 8 Parked 1 4 Downhill 2 Curve Right 77 Other, Explain in 1 No Controls 2 Brakes 14 Windows/ 3 Curve Left 30 Makini U -Turn Narrative 10 Person (including 3 Tires Windshield 5 Sag (bottom) 1 110verta ing/ 4 School Zone Sign/ Flagman, Officer, ❑ 88 Unknown Device 4 Lights (head, 15 Mirrors Passing Guard, etc.) 5 Traffic Control 13 Warning Sign signal, tail) 16 Truck Coupling/ Special Function 1 No Special Function 9 Arn ance 14 Intercity Bus Signal 77 Other, Explain in 6 Steering Trailer Hitch/ 30 Fire Truck 2 Farm Vehicle 15 Charter/Tour Bus 6 Stop Sign Narrative 7 Wipers Safety Chains of Motor Vehicle 3 Police 11 Farm Labor Transport 16 Shuttle Bus 7 Yield Sign 88 Unknown 9 Exhaust System 77 Other, Explain in 1 7 Taxi 12 School Bus 17 Farm Labor Bus 10 Body, Doors Narrative 8 Military 13 Transit/Commuter Bus 88 Unknown 11 Power Train 88 Unknown VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER 1 FREDERICK BRADLEY DETWILER 316.1925(1) CARELESS DRIVING AlPKX2P PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER 1 FREDERICK BRADLEY DETWILER 322.15(1) FAILED TO EXHIBIT D.L. UPON COMMAND Al PKX3P PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER 1 FREDERICK BRADLEY DETWILER 316.066(3)(C) DID NOT SUPPLY CURRENT INS CARD Al PKX5P HSMV 90010 S M (rev 10/10) Page ? of 6 HSMV 90010 S (P) (rev 10/10) Page 3 of 6 REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER • 1 161944 84212026 1 Driver ❑ VEHICLE # NAME 2 Non -Motorist PHONE NUMBER Check if Recommend 3 Passenger t 1 FREDERICK BRADLEY DETWILER 248-990-1516 Driver Re-exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 2025 LAVERS CIRCLE APT 401 DELRAY BEACH FL 33445 DATE OF BIRTH SEX DRIVER LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (IW) ❑ 1 Male 1 None 41nca acitating 2 Possible 5 Fatal (within 30 days) 1101 2 Female 02/24/1986 88 unknown 1 346261098143 1 02/28/2020 3 Non -Incapacitating 6 Non -Traffic Fatality DRIVER DL Type Required Endorsements Driver's Actions at Time of Crash 1 A 2 B 3 C 1 Yes 4 D/Chauffeur 2 No 5 E/Operator 3 No Req. Endorsement 3 let 26 Ran off Roadway aro Condition At 1 No Contributing Action 27 Disregarded other Traffic 2Operated MV in Careless or Sing Time of Crash N li ent Manner 8 1 Apparently Normal 28 Disregarded Other Road F_Z_1 5 6 E 0 er - Rest / P 3 Failed to Yield Right -of -Way Markings 3 Asleep or Fatigued 7 None4 Improper Backing 5 III (sick) or Fainted B 29 Over-Correcting/Over- Driver Distracted By 4 Other Inside the Vehicle 2nd 6lmproperTurn Steering 4th 6 Seizure, Epilepsy, Blackout 1 Not Distracted (explain in narrative) 2 Electronic Communication 5 External Distraction (outside the vehicle, 30 Followed too Closely 30 Swerved or Avoided :Due 7 Physically Impaired 11 Ran Red Light to Wind, Sli Slippery ❑ 8 Emotional (depression, pp y Surface, 12 Drove too Fast for Conditions MV, Object, Non -Motorist in angry, disturbed, etc.) 1 Devices (cell phone, etc.) ex Iain in narrative) 3 Other Electronic Device p . (navigation device, DVD player) 6 Texting 13 Ran StopSin 9 Under the Influence of g Roadway, etc. 15 Improper Passin8 31 Operated MV in Erratic, Medications/Drugs/Alcohol =Speed 7 Inattentive 17 Exceeded Reckless or Aggressive Manner 77 Other, Explain in Narrative ver Vision Obstructions 88 Unknown 21 Wrong Side or Wrong Way 77 Other Contributing Action 88 Unknown 25 Failed to Keep in Proper Lane 1 Vision Not Obscured 5 Load on Vehicle 9 Smoke • OR 74Trees/Crops 2 inclement Weather 6 Building/Fixed Object 30 Glare 3 Parked/Stopped Vehicle 7 Signs/Billboards 77 All Other, Explain 1/Bushes 8 Fog in Narrative Helmet Use (HU) Eye Protection (EP) Restraint Systems • • , 1DOT-Compliant 1 Yes (RS) • • Motorcycle Helmet 2 No 3 Motor Vehicle Seating Position: ROW OTHER 2 Other Helmet 3 Not Applicable 1 Not Applicable LOCATION: SEAT 3 No Helmet 2 None Used - Motor Vehicle Occupant Seat Row Other (LOC) ❑ ❑ 3 Shoulder and Lap Belt Used 1 it Bag Deployed 1 Left 1 Front 1 Not Applicable 5 Deployed -Other 4 Shoulder Belt Only Used (ABD) (knee, air belt, etc.) 5 Lap Belt Only Used 2 Middle 2 Second 2 Sleeper Section of Truck Cab 3 Right 3 Third 3 Other Enclosed Cargo Area Ejection (EJECT) 6 Deployed- 6 Restraint Used -Type Unknown 77 Other 4 Fourth 4 Unenclosed Cargo Area (explain in 77 Other Row 5 Trailing Unit 1 Not Ejected 1 Not Applicable Combination 7 Child Restraint System -Forward Facing ❑ 2 E'ected, Total/y, ❑ 2 Not Deployed 7Deployed-Curtain 8 Child Restraint System -Rear Facing 3 Deployed -Front 88 Deployment 9 Booster Seat narrative) 88 Unknown 6 Riding on Motor Vehicle Exterior (non- 3 Ejected, Partially 2 4 Not Applicable 4 Deployed -Side Unknown 10 Child Restraint Type Unknown 88 Unknown trailing unit) 88 Unknown 88 Unknown 77 Other, Explain in Narrative NON -MOTORIST Non -Motorist Description Non -Motorist Location At Time of Crash Action Prior to Crash 1 Pedestrian i Intersection - Marked Crosswalk 8 Sidewalk ❑5 Walking/Cycling on Sidewalk 2 Other Pedestrian (wheelchair, person in a 2 Intersection - Unmarked Crosswalk 9 Median/Crossing Island 6 in Roadway — Other (working, building, skater, pedestrian conveyance, etc.) ction—Other 3 Bicyclist 4 Midblock - Marked Crosswalk 11 Shared -Use Path or Trail 7 Adjacent to Roadway (e.g., F�4 ❑ 3 Interse30 Driveway Access playing, etc.) Other Cyclist 5 Travel Lane - Other Location 12 Non-Trafficway Area 1 Crossing Roadway shoulder, median) 5 Occupant of Motor Vehicle Not in Transport 6 Bicycle Lane 77 Other, Explain in Narrative 2 Waiting to Cross Roadway 8 Going to or from School (K-12) 7 Shoulder/Roadside 88 Unknown 3 Walking/Cycling Along 9 Working in Trafficway (parked, etc.) 6 Occupant of a Non Motor Vehicle Roadway with Traffic (in or (incident response) Non -Motorist Actions/Circumstances adjacent to travel lane) 10 None Transportation Device 7 Unknown Type of Non -Motorist t•t 1 No Improper Action 4 Walking/Cycling Along 77 Other, Explain in Narrative 2 Dart/Dash Roadway Against Traffic (in 88 Unknown 3 Failure to Yield Right -of -Way to travel lane) Safety Equipment or adjacent 1 None 5 Lighting ❑ 2 Helmet 6 Not Applicable 4 Failure to Obey Traffic Signs, Signals, or Officer 7 Entering/Exiting Parked/Standing 10 Improper Turn/Merge 3 Protective Pads Used 77 Other, Explain (elbows, knees, shins, etc.) in Narrative 2nd 5 In Roadway Improperly (standing, Vehicle 11 Improper Passing lying, working, playing) 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking 4 Reflective Clothing (jacket, 88 Unknown ❑ 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative backpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown ALCOHOL/DRUG/EMS SUSPECTED ALCOHOLTESTED: ALCOHOL TEST TYPE: ALCOHOL USE: 1 Test Not Given 1 Blood 1 2 Test Refused ❑ 2 Breath ❑ ALCOHOL BAC SUSPECTED DRUG TESTED: DRUGTESTTYPE: DRUGTEST RESULT: TEST RESULT: DRUG USE: 1 Test Not Given 1 Blood IF 's . tive 1 Pending ❑ 1 No ❑ 2 Test Refused 3 Urine ❑ 2 Negative 2 Yes 3 Test Given 3 Urine Ye [� 2 Completed 2 Yes 1 3 Test Given 77 Other, 3 Peding 88 Unknown 88 Unknown, if Tested 77 Other, Explain in 88 Unknown 88 Unknown 88 Unknown, if Tested Explain in Narrative 88 Unknown Narrative SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Transported ❑ 2 EMS 3 Law Enforcement 1 77 Other Ex Iain in Narrative 88 Unknown PERSON # VEHICLE # NAME ADDITIONAL PASSENGERS DATE OF BIRTH IN1 SEX 'LOC: S R O EJECT HU EP ABD RS 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 1 Not Transported ❑ 2 EMS 3 Law Enforcement 77 Other. Ex Iain in Narrative 88 Unknown PERSON # VEHICLE # NAME DATE OF BIRTH I W SEX LOC: S R O EJECT I HU EP ABD R5 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 1 Not Transported 2 EMS 3 Law Enforcement 77 Other Explain in Narrative 88 Unknown HSMV 90010 S (P) (rev 10/10) Page 3 of 6 REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 2 161944 84212026 1 Driver �VEHICLE# NAME PHONE NUMBER Check if 2Non-Motorist Recommend 3 Passenger STEVEN SCESA 312-371-9527 Driver Re-exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 300 S AUSTRALIAN AVE WEST PALM BEACH FL 33446 DATE OF BIRTH SEX DRIVER LICENSE NUMBER STATE EXPIRES INJURYSEVERITY (INJ) 1 Male 1 None 4lnwpacitating 10/01 /1968 2 Female 2 Possible 5 Fatal (within 30 days) 2 S8 Unknown 3 Non -Incapacitating 6 Non -Traffic Fatality •Driver's DL Type Required Endorsements Actions at Time of Crash 1A 2B 3 C tat 26 Ran off Roadway 3rd Condition At 1 No Contributing Action 27 Disregarded other Traffic ❑ 4 ED Chauffeur 2 No 2 Operated MV in Careless or Si Time of Crash 5 E/Operator 3 No Re Endorsement Q• 1 Apparently Normal ❑ Negligent Manner 28 Dsr arded Other Road Noneer - Rest 3 Failed to Yield Right Way 3 Asleep or Fatigued -of- Markings 7 4 Improper Backing 29 Over-Correcting/Over- 5111 (sick) or Fainted Driver Distracted By 4 Other Inside the Vehicle 2nd 6 Improper TurnSteering 4th 6 Seizure, Epilepsy, Blackout 1 Not Distracted (explain in narrative) 30 Followed too Closely 30 Swerved or Avoided : Due 7 Physically Impaired 2 Electronic Communication 5 External Distraction 11 Ran Red Light to Wind, Slippery Surface, ❑ 8 Emotional (depression, (outside the 12 Drove Fast for Conditions angry, disturbed, etc.) Devices (cell hone, etc.) vehicle, too MV, Object, Non -Motorist in p 3 Other Electronic Device explain in narrative) 13 Ran Stop Sign Roadway, etc. 9 Under the Influence of (navigation device, DVD player) 6 Texting 15 Improper Passing 31 Operated MV in Erratic, Medications/Drugs/Alcohol 7 Inattentive 17 Exceeded Posted Speed Reckless or Aggressive Manner 77 Other, Explain in Narrative Driver Vision Obstructions 1 88 Unknown 21 WrongtSior Wrong Way 77 Other Contributing Action 88 Unknown 25 Failed o Keep in Proper Lane 1 Vision Not Obscured 5 Load on vehicle 9 Smoke , , • • PASSENGER 2 Inclement Weather 6 Building/Fixed Object 30 Glare 3 Parked/Stopped Vehicle 7 Signs/Billboards 77 All Other, Explain a trees/crops/Bushes 8 Fog in Narrative Helmet Use (HU) Eye Protection (EP) Restraint Systems • • • • .. 1 DOT -Compliant 1 Yes (RS) Motorcycle Helmet 2 No ❑ Motor Vehicle Seating Position: LOCATION: SEAT ROW OTHER 2 Other Helmet 3 Not Applicable 1 Not Applicable (LOC) 3 Na Helmet 2 None Used -Motor Vehicle Occupant Seat Row Other ❑ ❑3 Shoulder and Lap Belt Used Air Bag Deployed 5 De to ed -Other 4 Shoulder Belt Only Used 1 Left 1 Front 1 Not Applicable p Y y 2 Middle 2 Second 2 Sleeper Section of Truck Cab(ABD) (knee, air belt, etc.) 5 Lap Belt Only Used 3 Right 3 Third 3 Other Enclosed Cargo Area Ejection (EJECT) 6 Deployed- 6 Restraint Used -Type Unknown 1 Not Applicable 7 Child Restraint System Forward Facing 77 Other 4 Fourth 4 Unenclosed Cargo Area❑ 1 Not Ejected Combination - (explain in 77 Other Row 5 Trailing Unit 2 E'ect A, Totally 2 Not Deployed 7 Deployed -Curtain 8 Child Restraint System - Rear Facing 3 Deployed -Front 88 Deployment 9 Booster Seat ❑ narrative) 88 Unknown 6 Riding on Motor Vehicle Exterior (non- 3 Ejected, Partially 4 Not Applicable 4 Deployed -Side Unknown 30 Child Restraint Type Unknown 88 Unknown trailing unit) 88 Unknown 88 Unknown 77 Other, Explain in Narrative NON -MOTORIST Non -Motorist Description Non -Motorist Location At Time of Crash Action Prior to Crash 5 Walking,/Cycling on Sidewalk 2 Other Pedestrian (wheelchair, person in a 2 Intersection - Unmarked Crosswalk 9 Median/Crossing Island 6 In Roaddway — Other (working, 1 Pedestrian 1 Intersection - Marked Crosswalk 8 Sidewalk El skater, pedestrian conveyance, etc.) 3 Intersection —Other 10 Driveway Access playing, etc.) ❑building, 3 Bicyclist 4 Midblock - Marked Crosswalk 11 Shared -Use Path or Trail 7 Adjacent to Roadway (e.g., ❑ 3 4 Other Cyclist 7 5 Travel Lane - Other Location 12 Non-Trafficway Area 1 Crossing Roadway shoulder, median) 5 Occupant of Motor Vehicle Not in Transport 6 Bicycle Lane 77 Other, Explain in Narrative 2 Waiting to Cross Roadway 8 Going to or from School (K-12) (parked, etc.) 7 Shoulder/Roadside 88 Unknown 3 Walking/Cycling Along 9 Working in Trafflcway 6 Occupant of a Non -Motor Vehicle Roadway with Traffic (in or (incident response) Non -Motorist Actions/Circumstances ad adjacent to travel lane) 10 None Transport ation Device 7 Unknown Type of Non-Motorist1 No Improper Action 4 Walking/Cycling Along 77 Other, Explain in Narrative 2 Dart/Dash Roadway Against Trac (in 88 Unknown Traffic Safety Equipment fat ❑ 3 Failure to Yield Right -of -Way lane) or adjacent to travel 1 None 5 Lighting 1 4 Failure to Obey Traffic Signs, 2 Helmet 6 Not Applicable 2 Signals, or Officer 7 Entering/Exiting Parked/Standing 10 Improper Turn/Merge 3 Protective Pads Used 77 Other, Explain 5 In Roadway Improper) (standing, Vehicle 11 Improper Passing (elbows, knees, shins, etc.) in Narrative 2nd lying, working, playing 8Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking [:] 4 Reflective Clothing Qacket, 88 Unknown 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative backpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown ALCOHOL/DRUG/EMS SUSPECTED ALCOHOL USE: ALCOHOLTESTED: 1 Test Not Given ALCOHOL TEST TYPE: 1 Blood ALCOHOL gqC TEST RESULT: SUSPECTED DRUG USE: DRUG TESTED: 1 Test Not Given DRUG TEST TYPE: DRUG TEST RESULT: 1 Blood 1 Positive 1 No ❑ 2 Yes 2 Test Refused ❑ 3 Test Given 2 Breath ❑ 3 Urine 1 Pending 2 Completed 1 No ❑ 2 Yes 1 2 Test Refused 3 Test Given 3 Urine 2 Negative 77 Other, 3 Pending 88 Unknown 1 88 Unknown, if Tested 77 Other, Explain in 88 Unknown 88 Unknown 88 Unknown, if Tested Explain in Narrative 88 Unknown Narrative SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Transported ❑ 2EMS 3 Law Enforcement 2 BOYNTON BEACH FD 1610349 BETHESDA HOSPITAL ER 77 Other, Ex Iain in Narrative 88 Unknown ADDITIONAL PERSON p VEHICLE t♦ NAME DATE OF BIRTH [NI SEX LOC: 5 R O E1ECT HU EP ABD RS CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE SOURCE OF TRANSPORTTO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Transported ❑ 2 EMS 3 Law Enforcement 77 Other Explain in Narrative 88 Unknown PERSON ti �VEHICLE#� NAME DATE OF BIRTH �INJ SEX LOC: S R 0 1 EJECT HU I EP ABD RS CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE SOURCE OF TRANSPORTTO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Transported ❑ 2 EMS 3 Law Enforcement 77 Other Explain in Narrative 88 Unknown HSMV 90010 S (P) (rev 10110) Page 4 of 6 REPORTING AGENCY CASE NUMBER CRASH REPORT NUMBER 7842v12026 161944 BICYCLIST WAS RIDING HIS BICYCLE NORTH BOUND IN THE 4400 BLOCK OF N. OCEAN BLVD. HE WAS MAINTAINING THE RIGHT SHOULDER AND NOT DISRUPTING TRAFFIC. DRIVER OF V-1 WAS ALSO DRIVING NORTH BOUND IN THE 4400 BLOCK OF N. OCEAN BLVD. BEHIND THE BICYCLIST. AS V-1 APPROACHED THE BICYCLIST HE INADVERTANTLY DROVE TO THE RIGHT AND STRUCK THE REAR TIRE OF THE BICYCLIST. THIS SENT THE BICYCLIST FALLING OFF HIS BICYCLE INTO A GRASSY SWALE AREA ADJACENT TO THE ROADWAY. BOYNTON BEACH FIRE DEPARTMENT RESPONDED AND TRANSPORTED BICYCLIST TO BETHESDA HOSPITAL FOR A CHECKUP. DRIVER OF V-1 CITED FOR CARELESS DRIVING. ADDITIONAL PERSON # VEHICLE #NAME DATE OF BIRTHINJ SEX LOC: S R 0 EJECT HU 71-T== 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 1 Not Transported ❑ 2 EMS 3 Law Enforcement 77 Other Ex Iain in Narrative 88 Unknown PERSON # VEHICLE # NAME DATE OF BIRTH �'N' SEX LOC: S R 0 EJECT HU EP ABD RS CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE SOURCE OFTRANSPORTTO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTEDTO 1 Not Transported ❑ 2 EMS 3 Law Enforcement 77 Other, Ex Iain in Narrative 88 Unknown ADDITIONAL VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTINGOFFICER ID/BADGE NUMBER RANK & NAME DEPARTMENT FHP SO PSD OTHER j ❑ ❑ X ❑ 755 OFFICER WILSON GULF STREAM POLICE DEPARTMENT HSMV 90010 S (N) (rev 10/10) Page 5 of 6 REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 161944 784212026 S.R. A1A North Ocean Bv. Double Yellow Markings Z Not To Scale HSMV 90010 S (D) (rev 10/10) Page 6 of 6