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HomeMy Public PortalAboutPRR 19-2711 TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered via fax April 30, 2019 Colleen Rose [fax to: 203.321.8553] Re: GS #2711 (Police Report #19-0712) Would like a copy of police report #19-0712. Dear Colleen Rose [fax to: 203.321.8553]: The Town of Gulf Stream has received your public records request dated April 30, 2019. You should be able to view your original request at the following link: http://www2.gulf-stream.org/weblink/0/doc/123732/Page1.aspx We consider this request closed. Sincerely, Reneé Rowan Basel As requested by Rita Taylor Town Clerk, Custodian of the Records Hagendoorn Insurance Apr 30 2019 01:42pm Sword Statement for Traffic Crash Report Information Moto► VeMde cash lrWmation Is confidential and exempt from dbuiosure for a period of 60 days after the amh roPort is Met *31&066(211a) FWWa Statutn 110141. Obtdlnky cordidenttsl intormadon by someone vrho brows they ant not entitled to do so Is a f4bny violation. The uader Vwd requests the fct wMq cash report (date/totatfon/pardes: The undersigned sates that WaM or the ornniutlm represented qualify for L-nnm lata dlsdosure of the eraM report newn hs; to the exemption d*dW balow and does srraar or affbm that the MFormati n cont anW In a orash rapwt made mnflderuial by statute w111 not be used for any commatdal soikitanoa of saddeM Vkxtms, or kn" M61y be disclosed to any third party for the purpose of such softRo ion, & Mnt the period of time tiwt the Uftrulatfon renals; confidertlat. _ ,1 am a party lnvohved In tM crash I am a detail represerrbstiva to a party Invohwd In Ow cash: Florlds Bar Number I aim a licaand Insurance aasat to a pally Waived In the cash, tfial► lswror or Insurers to whkh"applied for Insurance enwrap, Florida Ucense Number I am a person under contract to provide Balms or underwrfdnt in formation to a quaWybn insurance company, Identified as: 1 am a proSMA ng authority, Florida Flair Number _ 1 ntprasent a radio or tetevlsfon station acensed by the Fit= or newspaper qualltkld to publish kpl notkss or a free newspaper of pneral droulatlon, at defined b►316AM(2)(b) Florlds statutes. Name of Pado/rekvision/Nva pe"r I npnsent a local, nate or federal agency that Is wthorixd by law to have &cows to these reports. Nam of bol/state/fedeal gpwy I rwasent a Victim Sevdoes Program, as defined in d1316.N1051, ilerida Statutes (ml;l• Name of Program: (Arca Code1 Takiftne Number 6i -state, zip code State of AorI4Yd l e1 County of Swam (er afflrma+) ore bed befme OM? day of j / . 20� eq Persma0y known_or Produced tdentlfketlon Type of entd ation Produr:rd: Prf}n type or Stamp, Comn"oned Name of Notary NSMV-94010 (Fiev.12/14) Signature of Notary Public or Certi>Aed tow Enforcement or Carredlonal Officer 36 P002/002 This Traffic Crash Report can be purchased online at: www.buycrash.com WAS DOT PROPERTY INVOLVED IN THIS CRASH? FLORIDA TRAFFIC CRASH REPORT LONG FORM 0 SHORT FORM ❑ UPDATE F� TOTAL # OF VEHICLE SECTION(S) 2 (Shaded Areas) MAIL TO: DEPARTMENT OF HIGHWAY SAFETY &MOTOR VEHICLES TOTAL # OF PERSON SECTION(S) 2 TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING TOTAL # OF NARRATIVE SECTION(S) 1 TALLAHASSEE, FL 32399-0537 CRASH DATE TIME OF CRASH DATE OF REPORT REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 04/23/2019 9:18 AM 04/23/2019 119-0712 187073114 CRASH IDENTIFIERS COUNTY CODE CITY CODE COUNTY OF CRASH PLACE OR CITY OF CRASH CHECK IF WITHINIME REPORTED TIME DISPATCHED 06 44 PALM BEACH GULF STREAM CIN LIMITS 9:18 AM 9:18 AM TIME ON SCENE IME CLEARED SCENE CHECK IF r REASON (If Investigation NOT Complete) 6 Rear to Side Notified By: 1 Motorist 665 Dirt COMPLETED a El ❑ GOLFVIEW DR 88 Unknown 9:20 AM 10:39 AM Road System Identifier Indirectly Involved 7 Forest Road 2 Law Enforcement ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAY _F9 AT STREET ADDRESS # School Bus Related T LATITUDE AND LONGITUDE N OCEAN BLVD 1 4 Flog, Smog, Smoke 5 SleeVHaiV Rain, 5 Oil 6 Mud, Dirt, Gravel 7 Sand 1 No 2 YesSchoolBus We"26.489733 -80.054459 AT FEET MILESS N E W AT/FROM INTERSECTION WITH STREET, ROADMIGHWAY © (CHECK 6 Rear to Side OR FROM MILEPOST # 0 665 Dirt (standing/moving) a El ❑ GOLFVIEW DR 88 Unknown 2 Cloudy 7 Severe Crosswinds Road System Identifier Indirectly Involved 7 Forest Road Type of Shoulder Type of Intersection 5 Traffic Circle 1 Interstate 4 County 3 2 U.S. 5 Local 8 Private Roadway 9 Parking Lot t Paved ❑ 2 Unpaved 2 1 Nof at Intersection 2 Four -Way y Intersection 3 T -Intersection 6 Roundabout 7Five-Point, or More 77 Other, Explain in Narrative 3 State 6 Tumpike/roll 77 Other, Explain in Narrative 3 Curb 4 Y -Intersection P CRASH INFORMATION (CHECK IF PICTURES TAKEN) 1 Overturn/Rollover 10 Pedestrian 19 Impact Attenuator/Crash 30 Concrete Light Condition Weather Condition Roadway Surface Condition School Bus Related OWNER'S NAME Manner of Collision/Impact ❑ 1 Daylight 5 Dark -Not Lighted 9 1 2 Dusk 6Dark-Unknown 1 4 Flog, Smog, Smoke 5 SleeVHaiV Rain, 5 Oil 6 Mud, Dirt, Gravel 7 Sand 1 No 2 YesSchoolBus 4 Sideswipe, same direction 4 5 Sideswipe, Opposite Direction 3 Dawn Lighting 4 Dark -Lighted 77 Other, Explain in PROPERTY DAMAGE -OTHER THAN VEH. 6 Blowing Sand, Soil 1 ❑ 8 Water lol 1 Direct,lY ❑ Inved (CHECK 6 Rear to Side Narrative 1 Clear Dirt (standing/moving) 3 Yes, School Bus 7 Rear to Rear 1 Front to Rear 88 Unknown 2 Cloudy 7 Severe Crosswinds t D 77 Other, Explain in Dry P Indirectly Involved 2 Front to Front 77 Other, Explain in Narrative 3 Rain 77 Other, Explain in 2 Wet Narrative 88 Unknown Narrative 4 Ice/Frost 88 Unknown 3 Angle 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 2 Fire/Explosion 11 Pedalcycle Cusion 31 Other Traffic Barrier Location 1 On Roadway 14 3 Immersion 12 Railway vehicle (train, 20 Bridge Overhead Structure 32 Tree (standing) 2 Off Roadway 4 Jackknife 5 Cargo/Equipment engine) 21 Bridge Pier or Support 33 Utility Pole/Light Support 13 Animal 22 Bridge Rail 34 Traffic Sign Support 3 Shoulder 2 4 Median First Harmful Event Loss or Shift 14 Motor Vehicle in 23 Culvert 35 Traffic Signal Support 6 Gore 6 Fell/Jumped From Transport 24 Curb 36 Ohter Post, Pole or 7 Separator within Interchange Motor Vehicle 15 Parked Motor Vehicle 25 Ditch Support 8 In Parking Lane or 1 No 7 Thrown or Falling 16 Work Zone/Maintainance 26 Embankment 37 Fence Zone 2 Yes Object Equipment 27 Guardrail Face 38 Mailbox 9 Outside Right-of-way 1 8 Ran int Water/Canal 17 Struck By Falling, Shifting 28 Guardrail End 39 Other Fixed Object (wall, 10 Roadside 88 Unknown 9 Other Collision Cargo 29 Cable Barrier building, tunnel, etc.) 88 Unknown 18 Other Non -Fixed Obiect First Harmful Event Relation to Contributing Circumstances: Road g Worn, Travel -Polished Surface Contributing Circumstances: Environment Junction 4 5 RailwayGrade Crossing77 10 Raod Surface Condition (wet, 1 icy, snow, slush, etc. ❑ ❑Roadway) 14 Entrance[Exit Ram P 11 Obstruction in ❑ ❑ Cross - 1 Non -Junction 15 Crossover -Related 12 Debris 1 None 16 Shared -Use of Path or Trail 2 Intersection 13 Traffic Control Device 4 Work Zone construction/ 1 None 5 Animal(s) in Roadway o Lane 3Intersection-Related 17 AccelThrough maintenance/utilit Inoperative, Missing or Obscured Y 2 Weather Conditions 77 Other, Explain in 18 Through Roadway Roadway 4 Driveway/Alley Access 77 ether, Explain in Narrative 14 Non -Highway Work 6 Shoulders (none, low, soft, high) 77 Other, Explain in Narrative 3 Physical Obstruction(s) Narrative Related 88 Unknown 7 Rut, Holes, Bumps 8e Unknown 4 Glare 88 Unknown Work Zone Related Crash in Work Zone Type of Work Zone Workers in Work Zone Law Enforcement in Work 1 Before the First Work Zone 1 Lane Closure Zone Warning Sign 1 No 1 2Y s 2Advance Warning Area 3 Transition Area 2 Lane Shif/Crossover 3 Work on Shoulder or Median Work 4 Intermittent or Moving 1 No 2 Yes ❑ 1 No 2 Officer Present ❑ 88 Unknown 4 Activity Area 88 Unknown 3 Law Enforcement Vehicle 5 Termination Area 77 Other, Explain in Narrative P Only Present TNESSES NAME ADDRESS CITY & STATE ZIP CODE NAME ADDRESS CITY & STATE ZIP CODE NAME ADDRESS CITY & STATE ZIP CODE NON VEHICLE PROPERTY DAMAGE VEH. # PER # PROPERTY DAMAGE -OTHER THAN VEH. EST. AMT. OWNER'S NAME ❑ (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE VEH. # PER # PROPERTY DAMAGE -OTHER THAN VEH. EST. AMT. OWNER'S NAME ❑ (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE HSMV 90010 S 1 7 Page of _ VEHICLE # 1 Check if Commercial Reporting Agency Case Number HSMV Crash Report Number ❑ 19-0712 87073114 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES VIN 2 "arked Motor Vehicle 1 Check if Permanent 3 Working Vehicle 725YTQ FL 06/30/2020 Registration ❑ 3GKALPEV8KL173333 Hit and Run YEAR MAKE MODEL STYLE COLOR DAMAGE. EST. AMOUNT 1 No 1 1 Disabling 4 Minor 88 Unknown 3 None 2 Yes 2019 OMC TERRAIN UTILITY WHITE - WHI 2 Functional 88 Unknown $0.00 INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due VEHICLE REMOVED BY 1. Rotation CHUBS INS COM1112590601 to Damage: 2. Owner Request t No 2 Yes DRIVER 3. Driver 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) CURRENT ADDRESS CITY & STATE ZIP BUDGET RENTAL LLC 2005 BELVEDERE RD WEST PALM BEACH FL 33406 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check 6 Permanent VIN YEAR MAKE LENGTH AXLES tine: Registration ❑ Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES Two: Registration ❑ VEHICLE N S E W Off -Road Unknown ON STREET, ROAD, HIGHWAY AT EST. SPEED POSTED SPEED TOTAL LANES TRAVELING 1:12 ❑ ❑ ❑ ❑ I NORTH OCEAN BLVD AKA STATE RD AIA 110 35 2 HAZ. MAT. RELEASED HAZ. MAT. PLACARD NUMBER CLASS Area of Initial Impact ❑ Most Damaged Area 2 Ye ❑ 1 Ye ❑ 2 Yes 2 Yes 2 3 4 5 6 18 Undercamage 18 2 3 4 5 6 88 Unknown 88 Unknown MOTOR CARRIER NAME US DOT NUMBER 1 19 Overturn 19 15 16 17 6 20 Windshield 20 1 15 16 17 6 14 13 12 11 0 g 21 Trailer 21 14 13 1211 0 9 MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 16 I 16 (Sport) Utility Vehicle 1 Two -Way, Not Divided 1 Vehicle 10,000 lbs or less Placarded 8 Tractorfrnple for Hazardous Materials 17 Cargo Van (10,000 lbs 2 Two -Way, Not Divided, with a 9 Truck more than 10,000 lbs (4,536 (4,536 kg) or less) Continuous Left Tum Lane El Single -Unit Truck (2 -axle and GVWR kg), Cannot Classify 1 Passenger Car 18 Motor Coach 3 Two -Way, Divided, Unprotected more than 10,000 lbs (4,536 kg)) 10 Bus/Large van (seats for 9-15 2 Passenger Van 19 Other Light Trucks (10,000 lbs (painted >4 feet) Median 3 Single -Unit Truck (3 or more axles) occupants, including driver) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 4 Truck Pulling Trailer(s) 11 Bus (seats for more than 15 7 Motor Home 20 Medium/HeavyTrucks more Median Barrier 5 Truck Tractor (bobtail) ( occupants, including driver) 6 Truck Tractor/Semi-Trailer 77 Other, Explain in Narrative 8 Bus than Farm La lbs Vehicle kg)) 5 One -Way Trafficway 7 Truck Tractor/Double Truck 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 88 Unknown 12 Moped 77 Other, Explain in Narrative Trailer Type 13 All Terrain Vehicle (ATV) 88 Unknown 1 Single Semi Trailer 8 Pole Trailer 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type Comm/Non-Commercial TRAILER 1 TRAILER 2 13 Intermodal 3 Tank Trailer 10 Auto Transport 3 Van/Enclosed Box Container Chassis 1 Interstate Cartier El El 4 Saddle ilex railer 77 Other, Explain in F]4 Hopper 14 Vehicle Towing El 2 Intrastate Carrier 5 Boat Trailer Narrative Pole -Trailer Another Vehicle 3 Not in Commerce/Government 6 Utility Trailer 88 Unknown 6 Cargo Tank 15 Not Applicable 4 Not in Commerce/Other Truck 7 House Trailer 1 No Cargo 7 Flatbed (vehicle 10,000 lbs 1 10.000 lbs (4,536 kg) or less 2 Bus 8 Dump Most Harmful Event Non -Collision Comm P (4,536 kg) or less not 1 Overtum/Roilover GVWR/GCWR 2 10,001-26,000 lbs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard 2 Fire/Explosion 3 More than 26.000 lbs (11,793kg) 10 Auto Transport 77 Other, Explain in 3 Immersion 4 Not Applicable 11 Garbage/Refuse Narrative 4 Jackknife Collision with Non -Fixed Object Collision Fixed Object 12 Log 88 Unknown 5 Cargo/Equipment Loss or Shift 10 Pedestrian 29 Cable Banner Emergency 6 Fell/Jumped From Motor Vehicle 11 Pedalc cle 19 Impact Attenuator/Crash Cushion y 20 Bridge Overhead Structure 30 Concrete Traffic Barrier Vehicle Use 7 Thrown or Falling Object 12 Railway Vehide (train, engine) 31 Other Traffic Barrier Sequence of Events 8 Ran into Water/Canal 13 Animal 21 Bridge Pier or Support ❑ 4 32 Tree (standing) 9 Other Non -Collision 14 Motor Vehide in Transport 22 Bridge Rail 33 Utility Pole/Light Support 1 23 Culvert 1st 2nd 15 Parked Motor Vehicle 34 Traffic Sign Support F-91 F-1140.46 Sequence of Events only] 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 1 No 40 equipment Failure (blown tire, Equipment 25 Ditch 36 Other Post, Pole, or Support 2 Yes brake failure, etc.) 17 Struck By Falling, Shifting Cargo or 26 Embankment 37 Fence 41 Separation of Units Anything Set in Motion b Motor 27 Guardrail Face 88 Unknown 3rd 4th p Y< 9 Y 38 Mailbox ❑ 42 Ran Off Roadway, Right Vehicle 28 Guardrail End 39 Other Fixed Object (wall, 43 Ran Off Roadway, Left 18 Other Non -Fixed Object buildin , tunnel etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Cross Centerline 1 Straight Ahead 13 Stopped in Traffic ❑ ❑ Roadway Grade 46 Downhill Runaway 3 Turning Left 14 Slowing This Vehicle 1 Level 4Backing 15 Negotiating a Curve 8 Flashing Signal 1 None 2 Hillcrest 17 5 Turning Right 16 Leaving Traffic Lane 9 Railway Crossing 2 Brakes 13 Wheels I Roadway Alignment 1 No Controls 3 Uphill 6 Changing Lanes 17 Entering Traffic Lane Device 4 School Zone Sign/ 3 Tires 14 Windows/ 4 Downhill 1 Straight 8 Parked 77 Other, Explain in Narative 10 Person (including 1 Device 4 Lights (head, Windshield 5 Sag (bottom) 2 Curve Right 10 Making U -Tum 88 Unknown 5 Traffic Control Flagman, Officer, signal, tail) 15 Mirrors 3 Curve Lett 11 Overtaking/Passing Guard, etc.) Signal 6 Steering 16 Truck Coupling Special Function 1 No Special Function 9 Ambulance 14 Intercity Other, Explain in ty Bus 6 Stop Sign 7 Wipers Trailer Hitch/ of Motor Vehicle 1 2 Farm Vehicle 10 Fire Truck 15 Charter/tour Bus 7 Yield Sign Narrative9 Exhaust System Safety Chains 3 Police 11 Farm Labor Transport 16 Shuttle Bus 88 Unknown 10 Body, Doors 77 Other, Explain in 7 Taxi 12 School Bus 17 Farts Labor Bus11 Power Train Narrative 8 Military 13 Transit/Commuter Bus 88 Unknown 12 Sus ension 88 Unknown VIOLATIONS 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 90010 S 2 7 Page of _ PERSON # 1 Reporting Agency Case Number HSMV Crash Report Number 19-0712 87073114 1 Driver VEHICLE # NAME PHONE NUMBER heck if ❑ 2'Non-Motorist 1 1 Recommend 3 Passenger KATHERINE KNIGHT CLARK (203) 921-9896 Driver Re-exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 209 W LYON FARM DR GREENWICH CT 06831-4353 DATE OF BIRTH SEX: 1 Male 188 ❑ DRIVERS LICENSE NUMBER STATE EXPIRES INJURY 1 SEVERITY (INJ) 4 Incapacitating None 5 Fatal 30 ❑ 09/27/1953 2 Female Unknown 094631201 CT 2 09/27/2021 3 Possible (within days) Non -Incapacitating 6 Non -Traffic Fatality DRIVER DL Type Required Endorsements list Drivers Actions at Time of Crash aro Condition At ❑ I A 2 8 3 C1 No Contribution Action 26 Ran off Roadway Time of 1 4 D/Chauffeur 3] 1 Yes 2 Operated MV in Carelss or 27 Disregarded other Traffic Crash 5 E/Operator 2 No Negligent Manner Sign 6 E/Oper-Rest 3 No Req. Endorsement 3 Failed to Yield Right -of -Way 28 Disregarded Other Road 1 Apparently Normal 7 None 4 Improper Backing Markings 3 Asleep or Fatiuged 6 Improper Tum 29 Over-Correcting/Over 5 III (sick) or Fainted Driver Distracted By 4 Other Inside the Vehicle Steering 6 Seizure, Epilespsy, Blackout (explain in narrative) 10 Followed too Closely 7 Physically Impaired 1 Not Distracted 2nd 5 External Distraction 11 Ran Red Light 30 Swerved or Avoided. Due 8 Emotional (depression, 1 2 Electronic Communication 4th an disturbed, etc outside the vehicle, explain 1 12 Drove too Fast for Conditions Wind, Slippery Surface, MV, angry, Devices (cell phone, etc. i e in Hortative) 13 Ran Stop Sign Object, Non -Motorist in 9 Under the Influence of 3 Other Electronic Device O 6 Textin 15 Improper Passing1 Medications/Drugs/Alcohol (navigation device, DVD player) 7 Inattentive 17 Exceeded Posted Speed Roadway, etc. 77 Other, Explain in Narrative P 31 Operated in Erratic, 88 Unknown 88 Unknown 21 Wrong Side of Wrong Way Reckless orAgreessive Manner gr DRIVER VISION OBSTRUCTIONS 25 Failed to Keep in Proper Lane 77 Other Contributing Action 1 Vision Not Obscured 5 Load on Vehicle 9 Smoke 1 2 Inclement Weather 6 Building/Fixed Object 10 Glare DRIVER OR PASSENGER 3 Parked/Stopped Vehicle 7 Signs/Billboards 77 Other, ❑ All Explain 4 Trees/Crops/Bushes 8 Fog in Narrative Helmet Use (HU) Eye Protection (EP) Restraint Systems DRIVER OR PASSENGER ❑ 1 DOT -Compliant 1 Yes F (RS) SEAT ROW OTHER Motorcycle Helmet 2 No ❑ Motor Vehicle Seating Position: LOCATION. 2 Other Helmet 3 Not Applicable t Not Applicable (non -motorist) Seat Row Other (LOC) 1 1 1 3 No Helmet 2 None Used - Motor Vehicle Occupant 3 Shoulder and Lap Belt Used 1 Left 1 Not Applicable 1 Front pp4 Shoulder Belt Only Used 2 Middle 2 Sleeper Section of Truck Cab Air Bag Deployed 5 Lap Belt Only Used 3 Right 2 Second 3 Other Enclosed Cargo Area Ejection (EJECT) 5 De, air b Deployed -Other 6 Restraint Used - Type Unknown 3 Third g (knee, air belt, etc.) YF 77 Other 4 Unenclosed Cargo Area 1 Not Ejected ❑ 1 Not Applicable 7 Child Restraint System - Forward Facin (explain in 4 Fourth g 2 Ejected, Totally 1 6 Deployed- Y 9 5 Trailing Unit 4 I Y 2 Not Deployed Combination 8 Child Restraint System -Rear Facing g narrative) 77 Other Row 3 Ejected, 3 Deployed -Front 7 Deployed-Curtain9 Booster Seat 6 Riding on Motor Vehicle Exterior (non- Partially 4 Deployed -Side 88 Unknown 88 Unknown 10 Child Restraint Type Unknown 88 Deployment YP trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown Ncn-Motorist Description 1 Petlestrian Non -Motorist Location At Time of Crash 8 Sidewalk Action Prior to Crash 1 Intersection - Marked Crosswalk 5 Walking/Cyclingon Sidewalk ❑ 9 Median/Crossing Island ❑ 2 Other Pedestrian (wheelchan, person in a building, skater, pedestrian conveyance, etc. 2 Intersection -Unmarked Crosswalk 10 Driveway Access 6 In Roadway — Other (working, Y 3 Bicyclist y 3 Intersection - Other4 Midblock -Marked Crosswalk 11 Shared -Use Path or Trail playing, etc.) 1 Crossing Roadway 4 Other Cyclist y 4 Midblock -Marked Crosswalk 12 Non-Traffcwa Area 7 Adjacent to Raodway (e.g., Y 2 Waiting to Cross Roadway 5 Occupant of Motor Vehicle Not in Transport 5 Travel Lane - Other Location shoulder, median 77 Other, Explain in Narrative 3 Walking/CyGing Along ) (parked, etc.) 6 Bicycle Lane 88 Unknown 8 Going to or from School (K-12) Roadway with Traffic (in or 6 Occupant of a Non -Motor Vehicle 7 shoulder/Roadside 9 Working in Trafficway adjacent to travel lane) Transportation Device Non-Motonst Actionsicarcurnstances 4 Walking/Cycling Along (incident response) 10 None 7 Unknown Type of Non -Motorist 1 No Improper Action Roadway Against Traffic (in fst 2 Dart77 Other, Explain in Narrative /Dash adjac ent to travel lane) ❑ 3 Failurere to Yield 88 Unknown to eld Right -of -Way 4 Failure to Obey Traffic Signs 1 None Safety Equipment 5 Lighting 2 Helmet 6 Not ApplicableF-1Signals, 3 Protective Pads Used or Officer 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge 2M ❑ Vehicle 11 Improper Passing 77 Other, Explain (elbows, knees, shins, etc.) in Narrative 5 In Roadway Improperly (standing, g, g, playing) 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking lying. working, 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 ALCOHOL TESTED' ALCOHOL TEST TYPE: LCOHOL BAC USPECTED DRUG TESTED. DRUG TEST TYPE: DRUG TEST RESULT ALCOHOL USE: 1 No ❑ 1 Test Not Given 2 Test Refused ❑ 1 Blood 2 Breath ❑ EST RESULT ❑ DRUG USE: 1 1No 2 1 Test Not Given ❑ 1 Blood 3 Urine❑ 1 Positive ative ❑ 2 Yes 3 Test Given 77 Other, Explain 2 COMPLETED TED Yes 3 Test Given 77 Other, 3 Pending 88 Unknown 88 Unknown, if Tested in Narrative 88 UNKNOWN 8 Unknown 88 Unknown, 0 Tested Explain in Narrative 88 Unknown 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, Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON # VEHICLE # AME DATE OF BIRTH INJ I SEX I LOC: S I R _"CT I HU I EP I ABD I 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 Nd T—p— 2 EMS Slaw Enlacement 77 Other, Explain In Narrative 8t1 Un1 r ❑J PERSON # VEHICLE # AME DATE OF BIRTH I INJ I SEX I LOC: S IR 1 O EJECT I HU I EP I ABD I RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER _T MEDICAL FACILITY TRANSPORTED TO 1 Nd TrarrcPM 2 EMS 3 Law EnfmcemeM 77 OINer, Ezplain in N— 88 Jni p a I HSMV 90010 S 3 7 Page of _ NARRATIVE Reporting Agency Case Number HSMV Crash Report Number CHARGE 19-0712 1 87073114 ON APRIL 23, 2019 AT APPROXIMATELY 0918 HOURS I WAS DISPATCHED TO THE AREA OF 2613 NORTH OCEAN BLVD IN REFERENCE TO A MOTOR VEHICLE ACCIDENT. THIS PARTICULAR LOCATION IS ALSO KNOWN AS STATE RD A1A. UPON MY ARRIVAL I OBSERVED A MOTOR VEHICLE COMPLETELY STOPPED AND DISABLED IN THE SOUTHBOUND LANE OF STATE RD A1A. THIS VEHICLE WAS LATER IDENTIFIED AS VEHICLE #2. 1 LOCATED VEHICLE #1 IN THE PRIVATE PROPERTY PARKING LOT OF 2613 NORTH OCEAN BLVD. VEHICLE #1 WAS DETERMINED TO BE A NON CONTACT VEHICLE. NEITHER VEHICLE HAD MADE CONTACT WITH EACH OTHER. THIS PARTICULAR AREA IS A TWO LANE ROADWAY TRAVELING IN A NORTHERLY AND SOUTHERNLY DIRECTION. THE ROADWAY IS DIVIDED BY A DOUBLE YELLOW LANE WITH A POSTED SPEED LIMITED OF 35 MPH. THE SOUTHBOUND SHOULDER AREA IS FLANKED BY SEVERAL TREES. THE POINT OF IMPACT TOOK PLACE ON NORTH OCEAN BLVD, SOUTH OF GOLFVIEW RD ADJACENT THE PROPERTY LOCATED AT 2613 NORTH OCEAN BLVD. DURING MY INITIAL INVESTIGATION AND INTERVIEW I OBTAINED VERBAL STATEMENTS FROM BOTH DRIVERS. DRIVER #1 (CLARK) STATED THAT SHE WAS COMPLETELY STOPPED IN THE PRIVATE DRIVEWAY OF THE PROPERTY LOCATED AT 2613 NORTH OCEAN BLVD COMPLETING A LEFT HAND TURN (SOUTHBOUND) ONTO NORTH OCEAN BLVD. DRIVER #1 FURTHER STATED THAT SHE HEARD A LOUD NOISE BEHIND HER, SHE LOOKED INTO HER REAR VIEW MIRROR AT WHICH POINT SHE OBSERVED VEHICLE #2 COLLIDE WITH THE TREES. SHE BELIEVES THAT HER ACTIONS MAY HAVE CAUSED VEHICLE #1 TO CRASH. DRIVER #1 CONCLUDED HER STATEMENT INDICATING SHE NEVER MADE CONTACT WITH VEHICLE #2 AND AS RESULT SUSTAINED NO DAMAGE OR INJURIES. DRIVER #2 (MOTT) STATED THAT SHE WAS TRAVELING ON NORTH OCEAN BLVD IN THE SOUTHBOUND LANE WHEN SUDDENLY VEHICLE #1 PULLED OUT FROM THE PRIVATE DRIVEWAY IN FRONT OF HER. AS A RESULT SHE TOOK EVASIVE ACTION SO AS TO AVOID COLLIDING WITH VEHICLE #1. DRIVER #2 ULTIMATELY DROVE OFF INTO SOUTHBOUND SHOULDER AREA SIDE SWIPING SEVERAL TREES. DRIVER #2 CONCLUDED HER STATEMENT THAT SHE WAS TRAVELING APPROXIMATELY 40 MPH PRIOR TO TAKING EVASIVE ACTION. SUMMARY: VEHICLE #1 SUSTAINED NO DAMAGE. VEHICLE #2 SUSTAINED EXTENSIVE DAMAGE TO THE PASSENGER SIDE FRONT HOOD AND FENDER AREA. THE TIRE WAS COMPLETELY DISLODGE OFF THE RIM. THE FRONT PASSENGER SIDE AIRBAG WAS DEPLOYED. VEHICLE #2 REQUIRED A TOW FROM THE SCENE. NEITHER VEHICLE'S HAD PASSENGERS. THE DRIVER'S SUSTAINED NO INJURIES AND MEDICAL ATTENTION WAS NOT REQUIRED. I WAS UNABLE TO LOCATE OR IDENTIFY ANY INDEPENDENT EYEWITNESSES TO THIS ACCIDENT. I OBSERVED SKID MARKS LEADING FROM THE SOUTHBOUND TRAVEL LANE LEADING UP TO THE FIRST POINT OF IMPACT WITH THE TREES. I OBSERVED CONTACT DAMAGE TO SEVERAL TREES WITHIN THE SOUTHBOUND SHOULDER. IT APPEARS THAT THE DAMAGE TO VEHICLE #2 AND THE TREES IS CONSISTENT WITH THE STATEMENT GIVEN BY DRIVER #2. CONCLUSION. BASED ON THE DAMAGE TO VEHICLE #2, TREES AND THE STATEMENTS GIVEN BY BOTH DRIVERS IT APPEARS THAT DRIVER #1 (CLARK) FAILED TO YIELD THE RIGHT AWAY TO VEHICLE #2 CAUSING THIS ACCIDENT. NO WRITTEN ENFORCEMENT ACTION TAKEN. END OF REPORT. ADDITIONAL PASSENGERS PERSON # VEHICLE # AME DATE OF BIRTH I INJ I SEX I LOCS I R 0 1 EJECT I HU I EP I ABD I 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 1Nal Tranep— 2 EMS S law E --n O ,. Explain in Nanal� EB Unknown ❑ PERSON # VEHICLE # AME DATE OF BIRTH INJ SEX I LOC' S I R O 1 EJECT I HU 17P7—m RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBERMEDICAL FACILITY TRANSPORTED TO 1 Not T. 1.. 2 EMS 3law EMocemml 77 O., Ezq , In N.—N Unbgw�n ❑ ADDITIONAL VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER ADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. L7D,3-/761 PATROL SERGEA B. O'DONNELL GULF STREAM POLICE DEPARTM POLCE DEPARTMENT I(PD)l HSMV 90010 S 4 7 Page of ��r t �� �� �� I ` �%�� 4 �� fI STATE ROAb' Jul A POSTED . SPEE04 ' 20 Tu f �� I f& 4 �� �� �� rB r'Y, Y�� 1 ��1 y VEHICLE # 2 Check if Commercial Reporting Agency Case Number HSMV Crash Report Number ❑ NAME OF VIOLATOR 19-0712 87073114 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES Check 0 Permanent VIN 2 Parked Motor Vehicle 1 1169JU FL IWBADP6340YBV65148 3 Working Vehicle 06/03/2019 Registration ❑ HNondRun ❑ 1 YEAR MAKE NAME OF VIOLATOR MODEL STYLE CHARGE COLOR DAMAGE: 1 Disabling 4 Minor 1 ❑ EST. AMOUNT 1$5,000.00 2 Yes 88 Unknown 2000 BMW 3281 STATION WAGON BLACK - BLK 3 Non tonal 88 Unknown INSURANCE COMPANY (DRIVER) GEICO GENERAL INSURANCE INSURANCE POLICY NUMBER Towed due to Damage: 2 VEHICLE REMOVED BY 1. Rotation Owner2. Request 1 ❑ 4487713146 1 No 2 Yes ZUCCALAS TOWING 3. vn er q Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ CURRENT ADDRESS CITY & STATE ZIP ZI ARIEL EVA MOTT 5076 ENSIGN LOOP NEW PORT RICHEY FL 34652 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check I Permanent VIN YEAR MAKE LENGTH AXLES One; Registration ❑ Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES Two: Registration ❑ VEHICLE N S E W Off -Road Unknown ON STREET, ROAD, HIGHWAY AT EST. SPEED POSTED SPEED TRAVELING 1:12 ❑❑ ❑ ❑ NORTH OCEAN BLVD AKA STATE RD AIA 40 35 ITOTALLANES 2 HAZ. MAT. RELEASED 1 No HAZ. MAT. PLACARD 1 No NUMBER CLASS Area of Initial Impact _ Most Damaged Area 02 03 2 Yes 88 Unknown ❑ 2 Yes 88 Unknown ❑ 2 3 4 5 6 7 19 Overtum 19 �18 Undercarr age 18 2 3 4 5 6 7 1 15 16 17 6 20 Windshield 20 1 15 16 17 6 MOTOR CARRIER NAME US DOT NUMBER 14 9 21 Trailer 21 14 9 13 12 11 0 13 12 11 0 MOTOR CARRIER ADDRESS CITY STATE I ZIP CODE PHONE NUMBER Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 1 6 (Sport) Utility Vehicle 1 1 1 Two -Way, Not Divided 1 Vehide 10,000 lbs or less Placarded 8 Tracton Triple for Hazardous Materials 9 Truck more than 10,000 lbs (4,536 17 Cargo Van (10,000 lb as (4,536 kg) a less) 2 Two -Way, Not Divided, with a Continuous Left Tum Lane ❑ 2 Single -Unit Truck (2 -axle and kg), Cannot Classify 1 Passenger Car 18 Motor Coach more than 10,000 lbs (4,536 kg)))) 10 Bus/Large van (seats for 9-15 3 Two -Way, Divided, Unprotected 2 Passenger Van 19 Other Light Trucks (10,000 lbs (painted >4 feet) Median 3 Single -Unit Truck (3 or more axles) occupants, including driver) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 4 Truck Pulling Trailer(s) 11 Bus (seats for more than 15 ruc 5 Truck Tractor bobtail 7 Motor Home 20 Medium/Heavy Trucks (more Median Barrier (bobtail) occupants, including driver) 8 Bus than 10,000 lbs (4,536 kg)) One -Way Traffic6 Truck Tractor/Semi-Trailer 77 Other, Explain in Narrative 5 One -y way 11 Motorcycle 21 Farm Labor Vehicle 7 Truck Tractor/Double Truck 88 Unknown 88 Unknown 12 Moped 77 Other, Explain in Narrative Trailer Type 13 All Terrain Vehicle (ATV) 88 Unknown 1 Single Semi Trailer 8 Pole Trailer 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type Comm/Non-Commercial TRAILER t TRAILER 2 13 Intermodal 3 Tank Trailer 10 Auto Transport Carrier 1 Interstate Caer El ❑ 4 Saddle MountrFrailer 77 Other, Explain in F-13 Van/Enclosed Box Container Chassis 5 Boat Trailer Narrative 4 Hopper 14 Vehicle Towing 5Utility 2 Intrastate Carrier Trailer 88 Unknown 5 Pole -Trailer Another Vehicle 3 Not in Commerce/Govemment 6 Cargo Tank 15 Not Applicable 7 House Trailer 1 No Cargo Applicable 4 Not in Commerce/Other Truck 7 Flatbed (vehicle lbs Most Harmful Event Non -Collision 1 10,000 lbs 4,536 k or less 2 Bus 8 Dam Comm ( 9) p (4,536 kg) or less not 1 Overturn/Rollover GVWR/GCWR 2 10,001-26,000 lbs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard 2 Fire/Explosion 3 More than 26,000 lbs (11,793kg) 10 Auto Transport 77 Other, Explain in 3 Immersion 4 Not Applicable 11 Garbage/Refuse Narrative 4 Jackknife Collision with Non -Fixed Object Collision Fixed Object 12 Log 88 Unknown 5 Cargo/Equipment Loss or Shift 10 Pedestrian 29 Cable Barrier Emergency 1419 Impact Attenuator/Crash Cushion 6 Fell/Jumped From Motor Vehicle 11 Pedalc cle y 30 Concrete Traffic Barrier Vehicle Use 7 Thrown or Falling Object 20 Bridge Overhead Structure 12 Railway Vehicle (train, engine) 31 Other Traffic Barrier Sequence of Events 8 Ran into Water/Canal 13 Animal 21 Bridge Pier or Support 32 Tree (standing) 9 Other Non -Collision 33 Utility Pole/Light Support 1 14 Motor Vehicle in Transport 22 Bridge Rail23 Culvert 1st 2nd 15 Parked Motor Vehicle 34 Traffic Sign Support [40.46 Sequence of Events only] 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 14 42 40 equipment Failure (blown tire, 1 No Equipment 25 Ditch 36 Other Post, Pole, or Support brake failure, etc.) 2 Yes 17 Struck By Falling, Shifting Cargo or 26 Embankment 37 Fence 3rd41 Separation of Units 4th 42 Ran Off Roadway, Right 88 Unknown Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox Vehicle 28 Guardrail End 39 Other Fixed Object (wall, 32 ❑ 43 Ran Off Roadway, Left ❑ 18 Other Non -Fixed Object building, tunnel, etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Cross Centerline Roadway Grade 46 Downhill Runaway 1 Straight Ahead 13 Stopped in Traffic This Vehicle 3 Turning Left 14 Slowing ❑ 1 Level 4 Backing 15 Negotiating a Curve 1 8 Flashing Signal ❑ 2 Hillcrest Roadway Alignment I 3 Uphill 1 None 1 5 Tuming Right 16 Leaving Traffic Lane 9 Railway Crossing 1 No Controls 2 Brakes 13 Wheels 6 Changing Lanes 17 Entering Traffic Lane Device 4 School 4 Downhill ❑ 1 Straight 5 Sag (bottom) 1 2 Curve Right Zone Sign/ 3 Tires 14 Windows/ 8 Parked 77 OtherExplain in Narrative Device 10 Person (including 4 Lights Windshield 10 Making U -Tum , 88 Unknown ndshield Flagman, Officer, 3 Curve Left 5 Traffic Control signal, tail) 15 Minors 11 Overtaking/Passing Guard, etc.) Signal 6 Steering 16 Truck Coupling 77 Other, Explain in Special Function 1 No Special Function 9 Ambulance 14 Intercity Bus 6 Stop Sign 7 Wipers Trailer Hitch/ 1 2 Farm Vehicle of Motor Vehicle 10 Fire Truck 15 CharterlTour Bus 7 Yield Sign Narrative 9 Exhaust System Safety Chains 88 Unknown 3 Police 11 Farm Labor Transport 16 Shuttle Bus 10 Body, Doors 77 Other, Explain in 7 Taxi 12 School Bus 17 Farm Labor Bus 11 Power Train Narrative 8 Military 13 Transit/Commuter Bus 88 Unknown 12 Suspension 88 Unknown 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 90010 S 6 7 Page of _ PERSON # 2 Reporting Agency Case Number HSMV Crash Report Number 19-0712 87073114 1 Driver VEHICLE # NAME PHONE NUMBER Check K ❑ 2 Non -Motorist 1 2 Recommend 3 Passenger ARIEL EVA MOTT (678) 925.9760 Diver Re-exam CURRENT ADDRESS (Number and Street) CITY 8 STATE ZIP CODE 5076 ENSIGN LOOP NEW PORT RICHEY FL 34652 DATE OF BIRTH 1SEX Male 2 ❑ DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4lncapacitating ❑ 2 Female 2 Possible 5 Fatal (within 30 days) 06/03/1993 88 Unknown M300005937030 FL 06/03/2027 3 Non -Incapacitating 6 Non -Traffic Fatality DL Type Required Endorsements tst Drivers Actions at Time of Crash 3rd Condition At ❑ 1A 2B 3C—No Contribution Action 26 Ran off Roadway Time of 1 5 4 D/Chauffeur 3 1 Yes 17 2 Operated MV in Carelss or 27 Disregarded other Traffic ❑ Crash F ❑ 5 E/Operator 2 No Negligent Manner Sign 6 E/Oper-Rest 3 No Req. Endorsement 3 Failed to Yield Right -of -Way 28 Disregarded Other Road 1 Apparently Normal 7 None 4 Improper Backing Markings 3 Asleep or Fatiuged Driver Distracted B 6 Improper Tum 29 Over-Correcting/Over 5 III (sick) or Fainted By 4 Other Inside the Vehicle Steering 6 Seizure, Epilespsy, Blackout (explain in narrative) 10 Followed too Closely 7 Physically Impaired 2nd 1 Not Distracted 8 Emotional $$ 5 External Distraction 11 Ran Red Light 30 Swerved or Avoided. Due (depression, 2 Electronic Communication outside the vehicle, explain 12 Drove too Fast for Conditions 4th angry, disturbed, etc.) ( P Wind, Slippery Surface, MV, Devices (cell phone, etc. 9 Under the Influence of in narrative 13 Ran StopSin ❑ O 3 Other Electronic Device ) 9 Object, Non -Motorist in 6 Texting 15 Improper Passing Roadway, etc. Medications/Drugs/Alcohol (navigation device, DVD player) 7 Inattentive 17 Exceeded Posted Speed 77 Other, Explain in Narrative P 31 Operated MV in Erratic, 88 Unknown 21 Wrong Side of Wrong Way Reckless orAgreessive Manner 88 Unknown DRIVER VISION OBSTRUCTIONS 25 Failed to Keep in Proper Lane 77 Other Contributing Action 1 Vision Not Obscured 5 Load on Vehicle 9 Smoke ,( 2 Inclement Weather 6 Building/Fixed Object 10 Glare DRIVER OR PASSENGER ❑ 3 Parked/Stopped Vehicle 7 Signs/Billboards 77 All Other, Explain 4 Trees/Crops/Bushes 8 Fog in Narrative Helmet Use (HU) Eye Protection (EP) Restraint Systems DRIVER OR PASSENGER ❑ t DOT -Compliant ❑ 1 yes (RS) SEAT ROW OTHER Motorcycle Helmet 2 No Motor Vehicle Seating Position: LOCATION: 2 Other Helmet 3 Not Applicable 1 Not Applicable (non -motorist) Seat Row Other (LOC) 1 1 3 No Helmet 2 None Used - Motor Vehicle Occupant 3 Shoulder and Lap Belt Used 1 Left 1 Front 1 Not Applicable 4 Shoulder Belt Only Used Air Ba Deployed 2 Might 2 Sleeper Section of Truck Cab g 5 Lap Belt Only Used 3 Right 2 Second 3 Other Enclosed Cargo Area Ejection (EJECT) ( Deployed -Other 6 Restraint Used - Type Unknown 77 Other 3 Third g ❑ (knee, air belt, etc.) YP 4 Unenclosed Cargo Area t Not Ejected 1 NotAppliceble 7 Child Restraint System -Forward Facing g 6 Deployed- y 9 4 Fourth 3 (explain in 2 Ejected, Totally 2 Not Deployed 8 Child Restraint System -Rear Facing 5 Trailing Unit 1Combination Y 9 g narrative) 77 Other Row 3 Ejected, 3 Deployed -Front 7 Deployed-Curtain9 Booster Seat 88 Unknown 6 Riding on Motor Vehicle Exterior (non- Partially 10 88 Unknown 4 Deployed -Side Child Restraint Type Unknown 88 Deployment YP trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown N n -Motorist Description 1 Perpestnan Non -Motorist Location At Time of Crash 8 Sidewalk Action Prior to Crash 1 Intersection -Marked Crosswalk 5 Walking/Cyclingon Sidewalk ❑ 9 Median/Crossing Island 2 Other Pedestrian (wheelchan, person in a building, skater, pedestrian conveyance, etc. 2 Intersection -Unmarked Crosswalk10 Driveway A 6 In Roadway –Other (working, Yccess 3 Bicyclist y 3 Intersection - Other4 Midblock -Marked Crosswalk 11 Shared -Use Path or Trail playing, etc.) 1 Crossing Roadway 4 Other Cyclist 4 Midblock -Marked Crosswalk 12 Non-Trafficwa Area 7 Adjacent to Raodway (e.g., Y 2 Waiting to Cross Roadway 5 Occupant of Motor Vehicle Not in Transport 5 Travel Lane - Other Location 77 Other, Explain in Narrative shoulder, median) P 3 Walking/Cycling Along a etc.) 6 Bicycle Lane 88 Unknown 8 Going to or from School (K-12) Roadway with Traffic (in or 6 Occupant 6 Occupant of allon-Motor Vehicle 7 shoulder/Roadside (iWorking in adjacent to travel lane) Transportation Device response) (incident response) Non -Motorist Ac ons ircums ances 4 Walking/Cycling Along 10 None 7 Unknown Type of Non-Motonst1 No Improper Action Roadway Against Traffic (in 1st 77 Other, Explain in Narrative 2 Dart/Dash or adjacent to travel lane) 3 Failure to Yield Right -of -Way 88 Unknown 4 Failure to Obey Traffic Signs 1 None Safety Equipment 5 Lighting 2 Helmet 6 Not Applicable 3 Protective Pads Used Signals, or Officer 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge 2nd ❑ 5 In Roadway Improperly Vehicle 11 Improper Passing 77 Other, Explain (elbows, knees, shins, etc.) in Narrative (standing, , g, playing) 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking lying, workin 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 ALCOHOUDRUG/EMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: LCOHOL BAC USPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT: ALCOHOL USE: 1 1 No2 1 Test Not Given Refused ❑ 1 Blood 2 Breath 3 Urine ❑ EST RESULT 1 PENDING ❑ 1:1[ RUG USE: 1 No 2 Test Not Test Ref Given d ❑ 1 Blood 1 nne❑ Positive Negative 2 Yes 3 Test G oe 77 Other, Explain 2 COMPLETED Yes 3 Test Gven 77 Other, 3 Pending88 Unknown 88 Unknown, if Tested in Narrative 88 UNKNOWN 8 Unknown 88 Unknown, if Tested Explain in Narrative 88 Unknown 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 i ❑ 77 Other, Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON # VEHICLE # AME PATE OF BIRTH INJ SEX LOC: S R ]7 CT 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 Na Tranepa 2 EMS 3 Lex EnforcenreM 77 Other, Explain in Narrative W Un1 m ❑ PERSON # VEHICLE # AME DATE OF BIRTH_"X SEX LOCS I R 1 O EJECT 1HU J EP I ABD I RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID —7 EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Transp— 2 EMS 3 Lew Elipament 77 C , Explain in Narrative W Unl— ❑ 1 HSMV 90010 S 7 7 Page of _