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PRR 19-2742
Renee Basel From:Azul Rosales <ARosales@hightowerlaw.net> Sent:Monday, August 5, 2019 2:00 PM To:Rita Taylor Subject:Public Records Request Saul Irving Attachments:Public Records Request Gulf Stream Police Department 8.5.19.doc.pdf Good afternoon, Please find correspondence attached. Should you have any questions or concerns, do not hesitate to contact the undersigned. Thanks! Azul Rosales Paralegal HIGHTOWER, STRATTON, NOVIGROD & KANTOR 330 Clematis Street Suite 201 West Palm Beach, Florida 33401 (561) 833-2022 Ext. 145 Fax (561) 833-2140 www.hightowerlaw.net Check us out on ! FACEBOOK www.facebook.com/HightowerPartnersPA Check us out on FACEBOOK! www.facebook.com/HightowerPartnersPA 1 Hightower, Stratton, Novigrod, Kantor...Florida Corporate Defense Attorneys ...proudly serving the needs of its clients for over 25 years...Good people, Great Results. PERSONAL & CONFIDENTIAL This email is covered by the Electronic Communications Privacy Act, 18 U.S.C. Sections 2510-2521. The information contained in this e-mail message is confidential and intended only for use of the individual or entity named above. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received the communication in error, or if any problems occur with the transmission, please immediately notify us by telephone (561) 833-2022. Thank you. SAVE A TREE - PLEASE DO NOT PRINT THIS EMAIL UNLESS YOU REALLY NEED TO. 2 THE LAW FIRM OF HIGHTOWER, STRATTON, NOVIGROD & KANTOR ORLANDO/JACKSONVILLE/TALLAHASSEE PALM BEACH / MARTIN / ST. LUCIE UTHHALL 330 CLEMATIS STREET 151 SOS ITE 140 `�"E HSNK WEST PALM BEACH,SUITE 201 33401 ORLANDO, FLORIDA 32751 (407) 352-4240 • FAX (407) 352-4201 (561) 833-2022 • FAX (561) 833-2140 TAMPA / ST. PETERSBURG / FT. MYERS MIAMI I FT. LAUDERDALE / THE KEYS 4427 WEST KENNEDY BOULEVARD SUITE 225 TAMPA, FLORIDA 33609 4770 BISCAYNE BOULEVARD SUITE 1200 MIAMI, FLORIDA 33137 (727) 209-1373 • FAX (727) 209-1383 (305) 539-0909 • FAX (305) 530-0661 Reply to: Palm Beach I Martin I St. Lucie August 5, 2019 VIA E-MAIL: rta\ for@ ,ulf-stream.on, Gulf Stream Police Department Custodian of Public Records Rita Taylor, Town Clerk 100 Sea Road, Gulf Stream, FL 33483 Public Records Request Re: Saul Irving D/O/B: 09/27/66 Dear Rita: This is a request under the Freedom of Information Act (5 U.S.C. § 552) and the Florida Sunshine Law, for copies and preservation of any and all public records, photographs, and recordings in your possession including, but not limited to: arrest records, incident reports, background information, traffic crash reports, any aliases, any investigative files (including recorded statements, interviews, photographs, measurements, etc.), and any other documentation regarding Saul Irving, D/ O/ B: 09/27/1966, including but not limited to records related to an incident that occurred on August 3, 2019 in Highland Beach, FL, that involves Saul Irving, including Florida Traffic Crash Report, CADS logs, dispatch logs, 911 logs, 911 audio, citations issued, etc. Please advise a page count and total for obtaining all requested records. Once a page count is received, our office will issue a check for requested records. Thank you and should you have any questions, please do not hesitate to contact our office. Respectfully, Azul Rosales arosales@hi,,,htowerlaw.net Paralegal to Herb L. Uzzi, Esquire WWW. HIGHTOWERLAW.NET TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered via e-mail August 28, 2019 Azul Rosales [mail to: Arosales@hightowerlaw.net] Re: GS #2742 (Public Records Request Saul Irving) This is a request under the Freedom of Information Act (5 U.S.C. § 552) and the Florida Sunshine Law, for copies and preservation of any and all public records, photographs, and recordings in your possession including, but not limited to: arrest records, incident reports, background information, traffic crash reports, any aliases, any investigative files (including recorded statements, interviews, photographs, measurements, etc.), and any other documentation regarding Saul Irving, D/O/B: 09/27/1966, including but not limited to records related to an incident that occurred on August 3, 2019 in Highland Beach, FL, that involves Saul Irving, including Florida Traffic Crash Report, CADS logs, dispatch logs, 911 logs, 911 audio, citations issued, etc. Please advise a page count and total for obtaining all requested records. Once a page count is received, our office will issue a check for requested records. Dear Azul Rosales [mail to: Arosales@hightowerlaw.net]: The Town of Gulf Stream has received your public records request dated August 5, 2019. The original public records request can be found at the following link: http://www2.gulf-stream.org/weblink/0/doc/159568/Page1.aspx The cost of producing these 35 pages of documents will be .15 per page, per Fla. Stat. § 119.07(4)(a). (35 pages at .15) = Deposit Due: $5.25 in cash or check. We have also attached an e-mail response from the Delray Beach Police Department that has links you can follow that will get you the dispatch log as well as 911 audio. Upon receipt of your deposit, the Town will use its very best efforts to further respond to your public records request in a reasonable amount of time. If we do not hear back from you within 30 days of this letter, we will consider this request closed. Sincerely, Reneé Rowan Basel As requested by Rita Taylor Town Clerk, Custodian of the Records Renee Basel From:Delray Beach Public Records Support <delraybeach@mycusthelp.net> Sent:Thursday, August 22, 2019 7:09 PM To:Renee Basel Subject:\[Records Center\] Police Department :: P003898-081519 Attachments: GS19-1433.pdf GS19-1433_(2).wav GS19-1433_radio___call.wav --- Please respond above this line --- To help prot ect your priva cy, August 22, 2019 W RE: PUBLIC RECORDS REQUEST of August 15, 2019., Reference # P003898-081519. Dear Executive Assistant Renee' Basel, The Delray Beach Police Department received a public information request from you on August 15, 2019. Your request mentioned: "This is a request under the Freedom of Information Act (5 U.S.C. § 552) and the Florida Sunshine Law, for copies and preservation of any and all public records, photographs, and recordings in your possession including, but not limited to: arrest records, incident reports, background information, traffic crash reports, any aliases, any investigative files (including recorded statements, interviews, photographs, measurements, etc.), and any other documentation regarding Saul Irving, D/O/B: 09/27/1966, including but not limited to records related to an incident that occurred on August 3, 2019 in Gulf Stream, FL, that involves Saul Irving, including Florida Traffic Crash Report, CADS logs, dispatch logs, 911 logs, 911 audio, citations issued, etc. Please advise a page count and total for obtaining all requested records." Based on the information you have provided, you have been provided all records responsive. There are no additional records to provide. For your convenience, I have attached them to this message. Sincerely, Delray Beach Police Department To monitor the progress or update this request please log into the Public Records Center To help prot ect your priva cy, W 1 To help prot ect your priva cy, W 2 TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered via e-mail September 20, 2019 Azul Rosales [mail to: Arosales@hightowerlaw.net] Re: GS #2742 (Public Records Request Saul Irving) This is a request under the Freedom of Information Act (5 U.S.C. § 552) and the Florida Sunshine Law, for copies and preservation of any and all public records, photographs, and recordings in your possession including, but not limited to: arrest records, incident reports, background information, traffic crash reports, any aliases, any investigative files (including recorded statements, interviews, photographs, measurements, etc.), and any other documentation regarding Saul Irving, D/O/B: 09/27/1966, including but not limited to records related to an incident that occurred on August 3, 2019 in Highland Beach, FL, that involves Saul Irving, including Florida Traffic Crash Report, CADS logs, dispatch logs, 911 logs, 911 audio, citations issued, etc. Please advise a page count and total for obtaining all requested records. Once a page count is received, our office will issue a check for requested records. Dear Azul Rosales [mail to: Arosales@hightowerlaw.net]: The Town of Gulf Stream has received your public records request dated August 5, 2019. The original public records request can be found at the following link: http://www2.gulf-stream.org/weblink/0/doc/159568/Page1.aspx Thank you for your deposit of $5.25 by check #4894 for the public records request described above, received by the Town on September 18, 2019. The response can be found at the link above. We consider this request closed. Sincerely, Reneé Rowan Basel As requested by Rita Taylor Town Clerk, Custodian of the Records Page 1 of 1 +amu Gulf Stream Police Department 246 Sea Road T T Gulf Stream, FL 33483 Phone: (561) 278-8611 Fax: (561) 276-2528 SUPPLEMENTAL OFFENSE REPORT Incident/Reclassification: TRAFFIC CRASH Report Status: ACTIVE Reporting Officer: OFC. RANDALL WILSON Zone: 04 Bureau: PATROL Name: CAROL ANN LUCAS Race: WHITE Date of Birth: 11/24/1968 Home Address: 4117 TUSCANY WAY BOYNTON BEACH Report Date/Time: Division: OTHER Complaint Number: 19-1433 08/05/2019 12:30 PATROL Sex: FEMALE 0 Cell Phone: (561) 376-8087 INCIDENT SUMMARY ON 08/05/2019 AT APPROXIMATELY 1230 HRS WHITE FEMALE, CAROL ANN LUCAS CAME TO THE GULF STREAM POLICE DEPARTMENT TO GET THE BICYCLE AND OTHER RELATED ARTICLES FOR THE VICTIM OF THIS ACCIDENT. ALL OF THE ITEMS ON THE PROPERTY FORM WERE IDENTIFIED AND SIGNED FOR BY MS. LUCAS. SHE ALSO WENT THROUGH A PUBLIC RECORDS REQUEST TO GET A COPY OF THE INITIAL REPORT. NO FURTHER. ti3. Gulf Stream Police Department 246 Sea Road Gulf Stream, FL 33483 Phone: (561) 278-8611 Fax: (561) 276-2528 Page 1 of 3 SUPPLEMENTAL OFFENSE REPORT Incident/Reclassification: TRAFFIC CRASH Report Status: REPORT ONLY Report Date/Time: Reporting Officer: SGT. BERNARD ODONNELL Zone: 4 Division: Bureau: SUPERVISOR OTHER 0 Business Name: BOYNTON BEACH FIRE AND RESCUE DEPARTMENT REPORTED BY 0 Business Name: PALM BEACH COUNTY FIRE AND RESCUE DISPATCH CTR Complaint Number: 19-1433 08/04/2019 11:45 PATROL PROPERTY Property Code: MISCELLANEOUS Property Status: HELD AWAITING OWNER Description: ROAD BIKE Held As Evidence: NO Property Disposition: HELD AWAITING OWNER Owner's Name: SAUL IRVING Recovery Location: FROM CRASH SCENE Recovery Officer: SGT. ODONNELL Brand: TREK Serial Number: WTU076CT078G Quantity: I Value: $2500 PROPERTY Property Code: MISCELLANEOUS Property Status: HELD AWAITING OWNER Description: WATER BOTTLES Held As Evidence: NO Property Disposition: HELD AWAITING OWNER Owner's Name: SAUL IRVING Recovery Location: ATTACHED TO BIKE Recovery Officer: SGT. ODONNELL Characteristics: BLACK AND WHITE Quantity: 2 Value: $20 PROPERTY Property Code: MISCELLANEOUS Property Status: HELD AWAITING OWNER Description: BIKE SHOES Held As Evidence: NO Property Disposition: HELD AWAITING OWNER Owner's Name: SAUL IRBVING Recovery Location: AT CRASH SCENE Recovery Officer: SGT. ODONNELL Brand: S -WORKS Characteristics: RED/WHITE Page 2 of 3 Quantity: Property Code: Description: Held As Evidence: Owner's Name: Recovery Officer: Brand: Quantity: Property Code: Description: Held As Evidence: Owner's Name: Recovery Officer: Brand: Quantity: Property Code: Description: Held As Evidence: Owner's Name: Recovery Officer: Brand: Serial Number: Quantity: Property Code: Description: Held As Evidence: Owner's Name: Recovery Officer: Quantity: Property Code: Description: Held As Evidence: Owner's Name: Recovery Officer: Quantity: Property Code: Description: Held As Evidence Owner's Name: Recovery Officer: Quantity: 1 MISCELLANEOUS BIKE HELMET NO SAUL IRVING SGT ODONNELL KASK 1 MISCELLANEOUS GLASSES NO SAUL IRVING SGT. ODONNELL OAKLEY 1 MISCELLANEOUS GPS SYSTEM NO SAUL IRVING SGT. ODONNELL GARMIN UNK 1 MISCELLANEOUS BIKE STORAGE BAG NO SAUL IRVING SGT. ODONNELL 1 MISCELLANEOUS TIRE REPAIR TOOL NO SAUL IRVING SGT. ODONNELL Complaint Number: 19-1433 Value: $100 PROPERTY Property Status: HELD AWAITING OWNER Property Disposition: HELD AWAITING OWNER Recovery Location: AT CRASH SCENE Characteristics: BLACK AND WHITE Value: $75 PROPERTY Property Status: HELD AWAITING OWNER Property Disposition: HELD AWAITING OWNER Recovery Location: AT CRASH SCENE Characteristics: CLEAR LENS W/RED TRIM Value: $150 PROPERTY Property Status: HELD AWAITING OWNER Property Disposition: HELD AWAITING OWNER Recovery Location: ATTACHED TO BIKE Value: $300 PROPERTY Property Status: HELD AWAITING OWNER Property Disposition: HELD AWAITING OWNER Recovery Location: ATTACHED TO BIKE Characteristics: BLACK SOFT MATERIAL Value: $50 PROPERTY Property Status: HELD AWAITING OWNER Property Disposition: HELD AWAITING OWNER Recovery Location: ATTACHED TO BIKE Characteristics: PLASTIC -YELLOW 1 Value: $5 PROPERTY MISCELLANEOUS Property Status: HELD AWAITING OWNER AIWCO 2 CARTRIDGE W -STEM DEVICE NO Property Disposition: HELD AWAITING OWNER SAUL IRVING Recovery Location: ATTACHED TO BIKE SGT. ODONNELL 1 Value: $2 INCIDENT SUMMARY Page 3 of 3 Complaint Number: 19-1433 ON AUGUST 3, 2019 AT APPROXIMATELY 0856 HOURS OFFICER T. SUTTON AND I WERE DISPATCHED VIA THE PALM BEACH COUNTY FIRE DISPATCH PAGER TO A REPORTED MOTOR VEHICLE CRASH. THE LOCATION WAS REPORTED TO BE AT 4333 NORTH OCEAN BLVD, GULF STREAM, FL. INITIAL REPORT INDICATED THAT A MOTORCYCLE WAS INVOLVED AND INJURIES WERE REPORTED. OFFICER T. SUTTON WAS THE FIRST GULF STREAM OFFICER ON SCENE ALONG WITH MEMBER'S FROM THE BOYNTON BEACH FIRE DEPARTMENT. UPON MY ARRIVAL AT APPROXIMATELY 0901 HOURS I OBSERVED WHAT APPEARED TO BE A BICYCLIST RECEIVING TREATMENT FROM THE PARAMEDICS. SUBSEQUENT INTERVIEW'S AND INVESTIGATION DETERMINED A MOTORCYCLE WAS NOT INVOLVED. I INTERVIEWED SEVERAL INDIVIDUAL'S WHO HAD STOPPED TO RENDER MEDICAL ASSISTANCE TO THE INJURED BICYCLIST. THE INDIVIDUAL'S HAD NOT WITNESSED THE SEQUENCE OF EVENTS LEADING UP TO CRASH SCENE. OFFICER SUTTON AND I WERE UNABLE TO IDENTIFY ANY INDEPENDENT EYEWITNESSES TO THE CRASH. BASED ON OUR PRELIMINARY INVESTIGATION IT REVEALED THAT A WASTE MANAGEMENT GARBAGE TRUCK WAS COMPLETELY STOPPED. THE GARBAGE TRUCK WAS LOCATED WITHIN THE NORTHBOUND TRAVEL LANE AND CEMENT SHOULDER. THE ENGINE WAS TURNED ON. A POINT OF REFERENCE IS IDENTIFIED AS THE PROPERTY LOCATED AT 4333 NORTH OCEAN BLVD (AKA) SR AIA. THE WASTE MANAGEMENT TRUCK WAS NOT OCCUPIED AT THE TIME OF IMPACT. THERE WERE TWO INDIVIDUAL'S THAT WERE IDENTIFIED AND DOCUMENTED IN THE INITIAL REPORT BY OFFICER T. SUTTON. THE INDIVIDUALS WERE DETERMINED TO BE EMPLOYEE'S OF WASTE MANAGEMENT COMPANY. THE TWO EMPLOYEE'S WERE PERFORMING THEIR DUTIES BY COLLECTING GARBAGE FROM THE PROPERTY IDENTIFIED AS 4333 NORTH OCEAN BLVD. THE INITIAL VERBAL INTERVIEW'S OBTAINED FROM THE WASTE MANAGEMENT EMPLOYEE'S DETERMINED THAT THE BICYCLIST CRASHED INTO THE REAR OF THE GARBAGE TRUCK. ONE OF THE WASTE MANAGEMENT EMPLOYEE'S HEARD ONLY THE IMPACT NOISE FROM THE BICYCLE AND GARBAGE TRUCK. THE EMPLOYEE'S DID NOT WITNESS THE SEQUENCE OF EVENTS LEADING UP TO THE CRASH. THE IDENTITY OF THE BICYCLIST IS DOCUMENTED UNDER OFFICER SUTTON'S INITIAL REPORT. THE PARAMEDICS INDICATED THAT THE BICYCLIST RECEIVED SIGNIFICANT INJURIES WHICH REQUIRED A TRAUMA ALERT. THE BICYCLIST SUSTAINED A HEAD INJURY WHICH RESULTED IN HIM BRIEFLY LOSING CONSCIOUSNESS. THE BICYCLIST REGAINED CONSCIOUSNESS WHILE STILL AT THE SCENE AND PRIOR TO BEING TRANSPORTED TO THE HOSPITAL. THE BICYCLIST HELMET SHOWED SIGNIFICANT SIGNS OF DAMAGE. THE BICYCLE SUSTAINED MINOR FRONT END DAMAGE. WE WERE UNABLE TO LOCATE OR IDENTIFY A SPECIFIC POINT OF IMPACT BETWEEN THE BICYCLIST AND THE REAR PORTION OF THE GARBAGE TRUCK. IN THE COURSE OF NOTIFICATION PROCEDURES I MADE TELEPHONE CONTACT WITH CHIEF. ALLEN. BASED ON THE INITIAL ASSESSMENT IT WAS DETERMINED THAT THE ACCIDENT SCENE WOULD BE PROCESSED BY OFFICER SUTTON AND I. WE OBTAINED PHOTOGRAPH'S AND MEASUREMENT'S. OFFICER SUTTON'S INTERVIEW WITH THE BICYCLIST AT THE SCENE AND HOSPITAL IS DOCUMENTED UNDER HIS INITIAL REPORT. I REMAINED ON SCENE UNTIL THE ARRIVAL OF THE HEAVY DUTY TOW TRUCK. THE TOW TRUCK WAS AT THE REQUEST OF THE WASTE MANAGEMENT COMPANY. I TOOK POSSESSION OF THE INJURED CYCLIST BICYCLE ALONG WITH HIS PERSONAL ITEMS. THESE ITEMS WERE TAKEN IN COURSE OF SAFEKEEPING PROCEDURES. I COMPLETED A PROPERTY INVENTORY RECEIPT AND MADE IT PART OF THIS REPORT. THE BICYCLE IS BEING HELD AT THE GULF STREAM POLICE DEPARTMENT PENDING ITS RETURN TO THE OWNER. NO FURTHER ACTION TAKEN. END OF REPORT. tRiL �, Gulf Stream Police Department 246 Sea Road Gulf Stream, FL 33483 Phone: (561) 278-8611 Fax: (561) 276-2528 Page 1 of 3 Incident Type: Location of Incident: Type of Premises: Time of Call: Time of Arrival: Time Completed: Officer Injured: Date/Time Reported: Occurred From: Domestic: Juvenile Involved: Reporting Officer: NON CRIMINAL OFFENSE REPORT TRAFFIC CRASH 4333 N. OCEAN BLVD. GULF STREAM FL 33483 HIGH WAY/ROAD WAY 0857 0900 1122 NO 08/03/2019 08:57 NO NO OFC. TODD SUTTON Name: SAUL J IRVING Race: WHITE Date of Birth: 09/27/1966 Occupation: UNK Home Address: 820 EASTVIEW AVE DELRAY BCH FL 33483 Hospital Conveyance: DELRAY MEDICAL CENTER Hospital Disposition: ADMITTED Name: MURANO ENEJUSTE Race: BLACK Date of Birth: 01/06/1960 Occupation: WASTE COLLECTION Home Address: 6054 BLUE STONE LN LAKE WORTH FL 33463 Business Address: 651 INDUSTRIAL WAY BOYNTON BCH FL 33426 Business Name: WASTE MANAGEMENT Name: JEFFERY BRIGGS Race: WHITE Date of Birth: 10/27/1978 Occupation: ROUTE SUPERVISOR Home Address: 648 BUNTING DR DELRAY BCH FL 33444 Complaint Number: 19-1433 Zone: 4 Processed By: OFC TODD SUTTON Other Units Notified: SGT O'DONNELL, CHIEF E. ALLEN Officer Killed/Assaulted: NO OTHER Sex: MALE Cell Phone: (561) 676-9676 Driver's License: I615790663470 FL Injury: YES OTHER Sex: MALE Cell Phone: (561) 891-2252 Business Phone: (561) 547-4000 Driver's License: E522540600060 FL OTHER Sex: MALE Employed: YES Cell Phone: (305) 801-9703 Yage l of 3 Business Address: 651 INDUSTRAIL WAY BOYNTON BCH FL 33426 Business Name: WASTE MANAGEMENT Name: SENECQUE LEVEQUE Race: BLACK Date of Birth: 10/24/1965 Occupation: WASTE COLLECTION Home Address: 3821 SET DR LAKE WORTH FL 33476 Business Address: 651 INDUSTRIAL WAY 10 BOYNTON BCH FL 33426 Business Name: WASTE MANAGEMENT Business Name: BOYNTON BCH FIRE RESCUE Business Name: PBC FIRE RESCUE Complaint Number: 19-1433 Driver's License: B620420783870 OTHER Sex: MALE Employed: YES Cell Phone: (786) 444-2816 Driver's License: L120780653840 FL OTHER Business Phone: (561) 742-6329 REPORTED BY Business Phone: (561) 616-7000 PROPERTY Property Code: MISCELLANEOUS Property Status: DAMAGED Description: ROAD BICYCLE Held As Evidence: NO Property Disposition: HELD AWAITING OWNER Weight: 10 Owner's Name: IRVING SAUL Recovery Location: 4333 N OCEAN BLVD Recovery Officer:SGT O'DONNELL Brand: TREK Serial Number: WTU076CT078G Characteristics: BLACK/WHT Quantity: 1 Value: $2500 Notes: HELD AT POLICE DEPT HOLDING FACILITY VEHICLE Code: TRAFFIC CRASH Owner's Name: WASTE MANAGEMENT INC Vehicle Make: FRHT Vehicle Model: #506814 Vehicle Year: 2007 Vehicle Type: TRUCK Vehicle VIN: 1FVHC3CS67HX24171 Vehicle Color: WHITE/GREEN Vehicle License #: N3038U License State: FL License Year: 2019 Vehicle Insured: YES Vehicle Towed: YES Insurance Company: ACE AMERICAN INSURANCE CO. Wrecker Co.: SHEEHAN'S TOWING Reason Towed: OWNER REQUEST INC Entered NCIC: NO VEHICLE Code: TRAFFIC CRASH Owner's Name: SAUL IRVING Vehicle Make: TREK Vehicle Model: ROAD BICYCLE Vehicle Type: OTHER Vehicle VIN: WTU076CT078G Vehicle Color: BLACK/WHITE Vehicle License #: N/A Vehicle Insured: UNK Vehicle Towed: NO Insurance Company: N/A Wrecker Co.: N/A Reason Towed: POLICE REQUEST INCIDENT SUMMARY SEE HSMV CRASH REPORT #87073116 gage s of i Lomplainl Number: 19-1433 FLORIDA TRAFFIC CRASH REPORT WAS DOT PROPERTY INVOLVED IN THIS CRASH? LONG FORM Q SHORT FORM M UPDATE F-1 TOTAL # OF VEHICLE SECTION(S) 1 (Shaded Areas) ,3 TOTAL # OF NARRATIVE SSECT( 8) MAIL TO: DEPARTMENT OF HIGHWAY SAFETY & MOTOR VEHICLES TOTAL # OF PERSON E TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING SECTION(S) 1 TALLAHASSEE, FL 32399-0537 CRASH DATE TIME OF CRASH DATE OF REPORT REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 08/03/2019 8:55 AM 1 08/03/2019 119-1433 187073116 CRASH IDENTIFIERS COUNTY CODE CITY CODE COUNTY OF CRASH PLACE OR CITY OF CRASH E I WITHIN IME REPORTED TIME DISPATCHED 06 5 Oil 6 Mud, Dirt, Gravel 7 Sand 1 PALM BEACH GULF STREAM CITY LIMITS 8:57 AM 8:58 AM TIME ON SCENE IME CLEARED SCENE E W REASON (If Investigation NOT Complete) Dirt Notified By: 1 Motorist OR FROM MILEPOST # 110:53 TCHECKIF COMPLETED hN 1 Clear 7 Severe Crosswinds n 9:01 AM AM 88 Unknown Road System Identifier 7 Forest Road 2 Law Enforcement ROADWAY INFORMATION (CHOOSE ONLY 7 OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAY Weather Condition AT STREET ADDRESS # School Bus Related AT LATITUDE AND LONGITUDE N OCEAN BLVD 4 Flog, Smog, Smoke 5 SleetMaill 1 Freezing Rain 5 Oil 6 Mud, Dirt, Gravel 7 Sand 4333 4 Sideswipe, same direction 5 Sideswipe, Opposite Direction In 26.503059 -80.053164 AT FEET MILES S E W ATIFROM INTERSECTION WITH STREET, ROAD,HIGHWAY Dirt (standing/moving) OR FROM MILEPOST # 166 7 Rear to Rear hN 1 Clear 7 Severe Crosswinds © N COUNTY RD Indirectly Involved 7a 88 Unknown Road System Identifier 7 Forest Road Type of Shoulder Front 88 Unknown Type of Intersection 5 Traffic Circle 8 Private Roadway First Harmful Event Non -Collision Collision Non -Fixed Object Collision with Fixed Object 1 Not at Intersection 6 Roundabout 1 Interstate 4 County ❑ 2 U.S. 5 Local 3 9 Parking Lot 1 Paved 1 2 Unpaved 1 ❑ 2 Four -Way Intersection 3 T -Intersection 7 Five -Point. or More 77 Other, Explain in Narrative 3 State 6 Tumpike/Toll 77 Other, Explain in Narrative 3 Curb 15 4 Jackknife engine) 21 Bridge Pier or Support 33 Utility Pole/Light Support 5 Cargo/Equipment 13 Animal 22 Bridge Rail 34 Traffic Sign Support 4 Y -Intersection 3 Shoulder 4 Median CRASH INFORMATION (CHECK IF PICTURES TAKEN( 'd 6 Gore 6 Fell/Jumped From Transport 24 Curb 36 Ohter Post, Pole or Light Condition Weather Condition Roadway Surface Condition School Bus Related OWNER'S NAME Manner of Collision/Impact 1 Daylight 5 Dark -Not Lighted 1 2 Dusk 6 Dark -Unknown 4 Flog, Smog, Smoke 5 SleetMaill 1 Freezing Rain 5 Oil 6 Mud, Dirt, Gravel 7 Sand 1 No 2 Yes, School Bus1:1 4 Sideswipe, same direction 5 Sideswipe, Opposite Direction 3 Dawn Lighting 6 Blowing Sand, Soil 8 Water 1 Directly Involved ® (CHECK 6 Rear to Side 4 Dark -Lighted 77 Other, Explain in Dirt (standing/moving) 3 Yes, School Bus 7 Rear to Rear Narrative 1 Clear 7 Severe Crosswinds 1 Dry 77 Other, Explain in Indirectly Involved 1 Front to Rear 77 Other, Explain in Narrative 88 Unknown 2 Cloudy 77 Other, Explain in 2 Wet Narrative 2 Front to Front 88 Unknown 3 Rain 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 3 Immersion 12 Railway vehicle (train, 20 Bridge Overhead Structure 32 Tree (standing) 2 Off Roadway 15 4 Jackknife engine) 21 Bridge Pier or Support 33 Utility Pole/Light Support 5 Cargo/Equipment 13 Animal 22 Bridge Rail 34 Traffic Sign Support 3 Shoulder 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 7 Thrown or Falling 16 Work Zone/Maintainance 26 Embankment 37 Fence Zone 1 No Object Equipment 27 Guardrail Face 38 Mailbox 2 Yes 8 Ran int Water/Canal 17 Struck By Falling, Shifting 28 Guardrail End 39 Other Fixed Object (wall, 9 Outside Right-of-way 10 Roadside 88 Unknown 9 Other Collision Cargo 29 Cable Barrier building, tunnel, etc.) 88 Unknown 18 Other Non -Fixed Object First Harmful Event Relation to Contributing Circumstances: Road 9 Worn, Travel -Polished Surface Contributing Circumstances: Environment Junction 1 5 Railway Grade Crossing 14 Entrance/Exit Ramp 1 icy, snow, slush, etc.) ❑ ❑ ❑ 10 Road Surface Condition (wet, 11 Obstruction in Roadway ❑ ❑ ❑ 1 Non -Junction 15 Crossover - Related t6 Shared -Use of Path or Trail 12 Debris 1 None 13 Traffic Control Device 1 None 5 Animals in Roadway () � Y 2 Intersection 17 AccelerationlDceleration Lane 4 Work Zone (construction/ Inoperative, Missing or Obscured P 9 2 Weather Conditions 77 Other, Explain in 3 Intersection -Related 18 Through Roadway 9 Y maintenance/utility 14 Non -Highway Work 3 Physical Obstruction(s) Narrative 4 Driveway/Alley Access 77 Other, Explain in Narrative 6 Shoulders (none, low, soft, high) 77 Other, Explain in Narrative 4 Glare 88 Unknown Related 88 Unknown 7 Rut, Holes, Bumps 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 Zane 1 No 1-1 2 Yes Warning Sign 2Advance Warning Area 3 Transition Area 2 Lane Shift/Crossover 3 Work on Shoulder or Median 4 Intermittent or Moving Work 1 No 2 Yes 1 No 2 Officer Present 88 Unknown 4 Activity Area 77 Other, Explain in Narrative 88 Unknown 3 Law Enforcement Vehicle 5 Termination Area , Only Present WITNESSES 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 8 Page of — VEHICLE # 1 Check if Commercial �/ fReportmgAgency Case Number HSMVCrashReportNumber ❑ -1487073116 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE GISTRATION EXPIRES VIN 2 ParkedMotorVehicle 3 Check H Permanent3 Working Vehicle N3038U FL /31/2019 Registration ❑ 1 FVHC3CS67HX24171 Hit and Run YEAR MAKE MODEL STYLE COLOR DAMAGE: EST. AMOUNT 1 No 1 Disabling 4 Minor 2 Yes 1 2007 FRHT M2 TK WHITE - WHI 2 Functional 3 88 Unknown 3 None 88 Unknown INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due VEHICLE REMOVED BY1. Rotation to Damage: 1 3. Owner, Request ACE AMERICAN INSURANCE CO 2 MMTH2527863A-09271 1 No 2 Yes ❑ SHEEHAN'S TOWING I 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) R11 CURRENT ADDRESS CITY 8 STATE ZIP WASTE MANAGEMENT 651 INDUSTRIAL WAY BOYNTON BEACH FL 33426 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Ch. Ft Permanent VIN YEAR MAKE LENGTH AXLES One: Registration ❑ Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check I 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 R ❑ [:] EJ❑ ❑ STATE ROAD AIA 0 35 2 HAZ. MAT. RELEASED HAZ. MAT. PLACARD NUMBER CLASS Area of Initial Impact Most Damaged Area 1 No ❑ 1 No ❑ 3 4 5 6 08 O8 3 4 5 6 2 Yes 1 2 Yes 1 2 7 18 Undercarriage 18 2 7 88 Unknown 88 Unknown 19 Overturn 19 1 15 16 17 8 1 15 16 17 8 MOTOR CARRIER NAME US DOT NUMBER 20 Windshield 20 14 13 1211 0 g 21 Trailer 21 14 13 12 0 8 MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 1 Vehicle 10,000 lbs or less Placarded 8 Tractor/Triple 16 (Sport) Utility Vehicle 1 1 Two-Way, Not Divided for Hazardous Materials 9 Truck more than 10,000 lbs (4,536 20 17 Cargo Van (10,000 lbs 2 Two-Way, Not Divided, with a 2 Single-Unit Truck (2-axle and GVWR kg), Cannot Classify (4,536 kg) or less) Continuous Left Tum Lane more than 10,000 lbs (4,536 kg)) 10 Bus/Large van (seats for 9-15 1 Passenger Car 18 Motor Coach 3 Two-Way, Divided, Unprotected 2 Passenger Van 19 Other Light Trucks (10,000 lbs (painted 14 feet) Median 3 Single-Unit Truck (3 or more axles) occupants, including driver) q Truck Pulling Trailer(s) 3 Pickup (4,536 kg) or less) 4 Two-Way, Divided, Positive 11 Bus (seats for more than 15 7 Motor Home 20 Medium/Heavy Trucks (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 Farn 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 3 Tank Trailer 10 Auto Transport 13 Intermodal 4 Saddle Mountrrrailer 77 Other, Explain in 3 HopperVan/En Box Container Chassis ❑ 1 Interstate Cartier ❑ ❑ 11 4 Hopper 14 Vehicle Towing 5 Boat Trailer Narrative 4 2 Intrastate Carrier 5 Pole-Trailer Another Vehicle 6 Utility Trailer 88 Unknown 3 Not in Commerce/Government 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 BLus Dump (4,536 kg) or less not Most Harmful Event Non-Collision Comm 2 10,001-26,000 lbs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard 1 Overturn/Rollover GVWR/GCWR 3 More than 26,000 lbs (11,793kg) 10 Auto Transport 77 Other, Explain in 2 Fire/Explosion 4 Not Applicable 11 Garbage/Refuse Narrative 3 Immersion 4 Jackknife Collision with Non-Fixed Object Collision Flxed Object 12 Log 88 Unknown 5 Cargo/Equipment Loss or Shift 10 Pedestrian 29 Cable Barrier Emergency 9 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 19 Impact Attenuator/Crash Cushion 20 Bridge Overhead Structure 30 Concrete Traffic Barrier Vehicle Use 7 Thrown or Falling Object 12 Railway Vehicle (train, engine) 31 Other Traffic Barrier 21 Bridge Pier or Support ❑ Sequence of Events B Ran into Water/Canal 13 Animal 32 Tree (standing) 1 9 Other Non-Collision 14 Motor Vehicle in Transport 22 Bridge Rail 33 Utility Pole/Light Support Sign 1st 2nd 15 Parked Motor Vehicle 23 Culvert 34 Traffic Si g Support ❑ F-1[40.46 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 88 Unknown 3rd 4th 41 Separation of Units Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox F142 Ran Off Roadway, Right Vehicle 28 Guardrail End 39 Other Fixed Object (wall, 43 Ran Off Roadway, Left 18 Other Non-Fixed Object burldinq nnel, etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Cross Centerline 1 Straight Ahead 13 Stopped in Traffic This Vehicle ❑ ❑ Roadway Grade 46 Downhill Runaway 3 Turning Left 14 Slowing 1 Level 4 Backing 15 Negotiating a Curve 1 8 Flashing Signal 1 None 2 Hillcrest 13 5 Tuming Right 16 Leaving Traffic Lane 9 Railway Crossing Roadway Alignment 1 No Controls 2 Brakes 13 Wheels 3 Uphill 6 Changing Lanes 17 Entering Traffic Lane Device 1 4 School Zone Sign/ 3 Tires 14 Windows/ 4 Downhill 1 Straight 8 Parked 77 Other, Explain in Narrative 10 Person (including 5 Sag (bottom) 1 2 Curve Right 10 Making U-Tum 88 Unknown Device Flagman, Officer, 4 Lights (head, Windshield LLJ 3 Curve Left 11 Overtaking/Passing 5 Traffic Control Guard, etc.) signal, tail) 15 Mirrors Signal 6 Steering 16 Truck Coupling Explain in Special Function 1 No Special Function 9 Ambulance 14 Intercity Bus 6 Stop Sign 77 Other, 7 Wipers Trailer Hitch/ EE of Motor Vehicle 2 Farm Vehicle 10 Fire Truck 15 hour Bus 7 Yield Sign 9 Exhaust System Safety Chains 3 Police 11 Farm Labor Transport 16 Shuttle B88 Unknown Narrative 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 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 8 Page of_ PERSON # 1 Reporting Agency Case Number HSMV Crash Report Number 19-1433 87073116 1 Driver VEHICLE # NAME PHONE NUMBER Check ff ❑ 2 Non-Motorist i I Recommend 3 Passenger Driver Re-exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE DATE OF BIRTH SEX: 1 Male ❑ DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4 Incapacitating 1 None 5 Fatal (within 30 days) 2 Female 88 Unknown 2 Possible 3 Non-Incapacitating 6 Non-Traffic Fatality DRIVM DL Type Required Endorsements 1st Drivers Actions at Time of Crash 3rd Condition At ❑ 26 3 C1 No Contribution Action 26 Ran off Roadway Time of ❑1A 4 D/Chauffeur 1 Yes 2 Operated MV in Carelss or 27 Disregarded other Traffic Crash ❑ F]NegligentManner Sign 5 E/Operator 2 No 1 Apparently Normal 6 E/Oper-Rest 3 No Req. Endorsement 3 Failed to Yield Right-of-Way 28 Disregarded Other Road 3 Asleep or Fatigued 7 None 4 Improper Backing Markings 5 III (sick) or Fainted 6 Improper Tum 29 Over-Correcting/Over Driver Distracted By 4 Other Inside the Vehicle Steering 6 Seizure, Epilespsy, Blackout (explain in narrative) 2nd 10 Followed too Closely 7 Physically Impaired 1 Not Distracted 5 External Distraction 11 Ran Red Light 8 Emotional (depression, 9 30 Swerved or Avoided : Due 2 Electronic Communication (outside the vehicle, explain 12 Drove too Fast for Conditions 4th angry, disturbed, etc.) ❑ P to Wind, Slippery Surface, MV, 9 Under the Influence of Devices (cell phone, etc. in narrative 13 Ran Sto Sin P 9 Object, Non-Motorist in 3 Other Electronic Device 6 Textin 15 Improper Passin 11 Medications/Drugs/Alcohol gcd Roadway, etc. device, DVD Ia er 77 Other, Explain in Narrative (navigation P Y ) 7 Inattentive 17 Exceeded Posted Speed 31 Operated MV in Erratic, p 88 Unknown 88 Unknown 21 Wrong Side of Wrong Way Reckless orAgreessive Manner 25 Failed to Keep in Proper Lane 77 Other Contributing Action DRIVER VISION OBSTRUCTIONS 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 ❑ 1 DOT-Compliant ❑ 1 Yes ❑ (RS) DRIVER OR PASSENGER Motorcycle Helmet 2 No SEAT ROW OTHER Motor Vehicle Seating Position: LOCATION 2 Other Helmet 3 Not Applicable 1 Not Applicable (non-motorist) Seat Row Other (LOC) 3 No Helmet 2 None Used - Motor Vehicle Occupant 3 Shoulder and Lap Belt Used 1 Left 1 Not Applicable 4 Shoulder Belt Only Used 1 Front Air Bag Deployed 2 Midde 2 Sleeper Section of Truck Cab 5 Deployed-Other 5 Lap Belt Only Used 2 Second 3 Right 3 Other Enclosed Cargo Area Ejection (EJECT) g (knee, air belt, etc.) 6 Restraint Used - Type Unknown 77 Other 3 Third [:]1 Not Ejected 1 Not Applicable 7 Child Restraint System - Forward Facing 4 Unenclosed Cargo Area e 6 Combination in 4 Fourth 2 Ejected, Totally 2 Not Deployed ed 8 Child Restraint System -Rear Facing 5 TrailingUnit Y Combination narrative) 77 Other Row 3 Ejected, 3 Deployed-Front 7Deployed-Curtain 9 Booster Seat e 88 Unknown 6 Riding on Motor Vehicle Exterior (non- Partial) 10 Child Restraint Type Unknown 88 Unknown y 4 Deployed-Side 88 Deployment Yp trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown NON-MOTORI 3r N n-Motorist Description 1 Pedestrian F-1 ❑ Non-Motorist Location At Time of Crash 8 Sidewalk ❑ Action Prior to Crash 1 Intersection - Marked Crosswalk 5 Walkin /C Gin on Sidewalk 9 Y g 2 Other Pedestrian (wheelchan, person in a 9 Median/Crossing Island 2 Intersection -Unmarked Crosswalk 6 In Roadway -- Other (working, building, skater, pedestrian conveyance, etc. 10 Drivewa Access y 3 Intersection - Other4 Midblock -Marked Crosswalk 11 Shared-Use Path Trail playing, etc.) se or 1 Crossing Roadway 3 Bicyclist 4 Other Cyclist 7 Adjacent to Raodway (e.g., 4 Midblock -Marked Crosswalk 12 Non-Trafficway Area 2 Waitingto Cross Roadway 5 Occupant of Motor Vehicle Not in Transport 5 Travel Lane - Other Location 77 Other, Explain in Narrative 3 Walking/Cycling shoulder, median ) Along 6 Bicycle Lane 8 Going to or from School (K-12) (parked, etc.) 88 Unknown 7 shoulder/Roadside Roadway with Traffic (in or 9 Working in Trafficway 6 Occupant of a Non-Motor Vehicle adjacent to travel lane) (incident response) Transportation Device Non-motonSt ACtionsicircumstances 4 Walking/Cycling Along 10 None 7 Unknown Type of Non-Motorist 1st 1No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative 2 Dart/Dash or adjacent to travel lane) 88 Unknown 3 Failure to Yield Right-of-Way 4 Failure to Obey Traffic Signs 1 None Safety Equipment 5 Lighting 2 Helmet 6 Not Applicable 3 Protective Pads Used ge Signals, or Officer 7 Entering/Exiting Parked/Standing 10 Improper Passing 22M❑ Vehicle 11 Improper Passing 5 In Other, Explain 77 O (elbows, knees, shins, etcin Narrative Roadway Improperly (standing, 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 ❑ ( 9 backpack, etc P �) 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 3 Urine ❑ EST RESULT 1 PENDING El DRUG USE 1 1 No ❑ 2 Test Not Given Test Refused 1 Blood 3 Urine1:1 1 Positive 2 Negative ❑ 2 Yes 3 Test Given 77 Other, Explain 2 COMPLETED Yes 3 Test Given 77 Other, 3 Pending 88 Unknown 88 Unknown, ff 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 Tran sported 2 EMS 3 Law Enforcement ❑ 77 Other, Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON # 1VEHICLE# AME DATE OF BIRTH INJ I SEX I LOC: S I R 0 EJECT I HU I 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 t Nd Tanepor aw 2 EMS S lEnfwcemaM 77 pier. Esp �n Nartatire 88 U ❑ PERSON # VEHICLE # AME DATE OF BIRTH I INJ I SEX I LOCS IR 1 O EJECT 1HU J I EP I ABD I RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO I Not Trawp 2 EMS 3 Law Enfacemenl r gher. E.plain in Nanniw N Unlmwen ❑ JEMS HSMV 90010 S 3 8 Page of — PERSON # 1 1 Driver VEHICLE # NAME 2 Non -Motorist I ❑ 3 Passenger 1 Not Distracted SAUL CURRENT ADDRESS (Number and Street) the vehicle, explain 820 EASTVIEW AVE in n narrative) 3 Other Electronic Device DATE OF BIRTH SEX: 7 Inattentive DRIB 88 Unknown 1 Male 1 ❑ 1OF ollowed too Closely 6 Occupant of a Non -Motor Vehicle P 2 Female 1 None Incapacitating 30 Swerved or Avoided Due 09/27/1966 88 Unknown 2 Possible 5 Fatal (within 30 days) 4 F112 13 Ran Stop Sign Object, Non -Motorist in F]1A263C DL Type Required F]4 Endorsements D/Chauffeur 5 E/Operator 6 E/Oper-Rest 1 Yes 2 No 3 No Req Endorsement 7 None HSMV Crash Report Number 19-1433 Driver Distracted By 4 Other Inside the Vehicle ❑ (explain in narrative) 1 Not Distracted 5 External Distraction 2 Electronic Communication the vehicle, explain Devices cell hone, etc. ( P in n narrative) 3 Other Electronic Device 6 Texting (navigation device, DVD player) 7 Inattentive IUMBER 88 Unknown Reporting Agency Case Number HSMV Crash Report Number 19-1433 87073116 26 Ran off Roadway 27 Disregarded other Traffic PHONE NUMBER Check I ❑ Sign 2 Intersection -Unmarked Crosswalk 10 5 3 Intersection - Other4 Midblock -Marked Crosswalk ❑ Recommend JONATHAN IRVING 6616769676 Driver Re-exam CITY 8 STATE ZIP CODE DELRAY BEACH FL 33483 IUMBER STATEEXPIRES Steering INJURY SEVERITY (INJ) 4 1OF ollowed too Closely 6 Occupant of a Non -Motor Vehicle P 2 Yes 3 1 None Incapacitating 30 Swerved or Avoided Due o onsActions/Circumstances Drove too Fast for Conditions 2 Possible 5 Fatal (within 30 days) 4 F112 13 Ran Stop Sign Object, Non -Motorist in 3 Non -Incapacitating 6 Non -Traffic Fatality 1st ❑ Drivers Actions at Time of Crash ❑1 No Contribution Action 2 Operated MV in Carelss or 26 Ran off Roadway 27 Disregarded other Traffic Ncn-Motorist Description 1 Petlestrian 2 Other Pedestrian in Negligent Manner Sign 2 Intersection -Unmarked Crosswalk 10 5 3 Intersection - Other4 Midblock -Marked Crosswalk ❑ 3 Failed to Yield Right -of -Way 28 Disregarded Other Road 11 4 Improper Backing Markings 4 Midblock -Marked Crosswalk 12 6 Improper Tum 29 Over-Correcting/Over 5 Travel Lane -Other Location 77 6 Bicycle Lane Other, Explain in Narrativeshoulder, median) P 3 Along 8 Going to or from School (K-12) Steering 2nd 1OF ollowed too Closely 6 Occupant of a Non -Motor Vehicle P 2 Yes 3 11 Ran Red Light 30 Swerved or Avoided Due o onsActions/Circumstances Drove too Fast for Conditions to Wind, Slippery Surface, MV, F112 13 Ran Stop Sign Object, Non -Motorist in tst 8 2 Dart/Dash 15 Improper Passing Roadway, etc. 3 Failure to Yield Right -of -Way 17 Exceeded Posted Speed 31 Operated MV in Erratic, 4 Failure to Obey Traffic Signs Signals, or Officer 7 21 Wrong Side of Wrong Way Reckless orAgreessive Manner m 5 In Roadway Improperly (standing, Vehicle 25 Failed to Keep in Proper Lane 77 Other Contributing Action 'vision "" vo""" 5 Load on Vehicle 9 Smoke 2 Inclement Weather 6 Building/Fixed Object 10 Glare 3 Parked/Stopped Vehicle 7 Signs/Billboards 77 All Other, Explain 4 Trees/Crops/Bushes 8 Fog in Narrative Helmet Use (HU) DRIVER OR PASSENGER 1 DOT -Compliant EAT ROW OTHER Motorcycle Helmet Motor Vehicle Seating Position: LOCATION. 2 Other Helmet Seat Row Other (LOC) 3 No Helmet 1 Left 1 Not Applicable 1 Front Air Bag [ 3rd 4th DRIVER OR PASSENGER Condition At Time of Crash ❑ 1 Apparently Normal 3Asleep or Fatigued 5111 (sick) or Fainted 6 Seizure, Epilespsy, Blackout 7 Physically Impaired 8 Emotional (depression, angry, disturbed, etc.) 9 Under the Influence of Medications/Drugs/Alcohol 77 Other, Explain in Narrative 88 Unknown Eye Protection (EP)I I Restraint Systems 1 Yes II_JI (RS) F-1 2 No 3 Not Applicable 1 Not Applicable (non -motorist) 2 None Used - Motor Vehicle Occupant 3 Shoulder and Lap Belt Used ed 4 Shoulder Belt Only Used 2 Middle 2 Second 2 Sleeper Section of Truck Cab econ 3 Right 3 Other Enclosed Cargo Area Ejection (EJECT) g 77 Other 3 Third 4 Unenclosed Cargo Area 1 Not Ejected (explain in 4 Fourth 2 Ejected, Totally narrative 5 Trailing Unit 3 Ejected, 77 Other Row 6 Ridingon Motor Vehicle Exterior non- Partial) 88 Unknown 88 Unknown ( y trailing unit) 4 Not Applicable 88 Unknown 88 Unknown 5 Deployed -Other (knee, air belt, etc.) 1 Not Applicable 6 Deployed- 2 Not Deployed Combination 3 Deployed -Front 7 Deployed -Curtain 4 Deployed -Side 88 Deployment Unknown 5 Lap Belt Only Used 6 Restraint Used -Type Unknown 7 Child Restraint System -Forward Facing 8 Child Restraint System -Rear Facing 9 Booster Seat 10 Child Restraint Type Unknown YP 77 Other, Explain in Narrative ALCOHOL BAC Ncn-Motorist Description 1 Petlestrian 2 Other Pedestrian in Non -Motorist Location At Time of Crash 8 Sidewalk Action Prior to Crash 1 Intersection - Marked Crosswalk 5 Walking/Cyclingon Sidewalk 9 Island $ (wheelchan, person a 3 building, skater, pedestrian conveyance, etc. 2 Intersection -Unmarked Crosswalk 10 5 3 Intersection - Other4 Midblock -Marked Crosswalk ❑ Dnvewa Access 6 In Roadway —Other (working, Driveway Ace Y Playing, etc.) 3 Bicyclist 11 Shared -Use Path or Trail 1 Cross Roadway 9 Y 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 6 Bicycle Lane Other, Explain in Narrativeshoulder, median) P 3 Along 8 Going to or from School (K-12) (parked, etc.) 88 7 shoulder/Roadside Unknown withWalking/Cycling Traffic Roadway Roadway with Traffic (in or g Working in Trafficway 6 Occupant of a Non -Motor Vehicle P 2 Yes 3 adjacent to travel lane) (incident response) Transportation Deviceon- o onsActions/Circumstances 4 Walking/Cycling Along 10 None 7 Unknown Type of Non -Motorist 1 No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative p 88 Unknown 88 tst 8 2 Dart/Dash or adjacent to travel lane) 88 Unknown 88 Unknown 3 Failure to Yield Right -of -Way SOURCE OF TRANSPORT TO MEDICAL FACILITY None Safety Equipment 5 Lighting ? Helmet6 4 Failure to Obey Traffic Signs Signals, or Officer 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge Not Applicable i Protective Pads Used 77 Other, Explain m 5 In Roadway Improperly (standing, Vehicle 11 Improper Passing elbows, knees, shins, etc.) in Narrative lying, working, playing) 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking I Reflective Clothing (jacket, 88 Unknown ❑ 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative )ackpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown At Cnwni /r1R11G/FMS SUSPECTED ALCOHOL TESTED. ALCOHOL TEST TYPE: ALCOHOL BAC SUSPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT: 2 Y OHOL USE: ❑ 1 No 1 1 Test Not Given � 2 Test Refused 1 Blood 2 Breath ❑TEST 3 Urine RESULT: ❑ 1 PENDING DRUG USE: 1 1 No 2 Test Not Given ❑ Test Refused 1 Blood ❑ Urine 1 Positive 2 Negative a 3 Test Given 77 Other, Explain 2 COMPLETED 2 Yes 3 Test Given 7 Other, 3 Pending 88 Unknown 88 Unknown, if Tested in Narrative 88 UNKNOWN 88 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 2 BOYNTON BEACH FIRE RESCUE #8369 DELRAY BEACH MEDICAL CENTER 77 Other, Explain in Narrative 88 Unknown ADDITI NAL PASSENGERS PERSON 11 VEHICLE # AME DATE OF BIRTH I INJ SEX LOC: S R 0 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 Na Trarupo 2 EMs 3 — EnlucemeM n OtM . Explain in Nanalrve 88 Unkgw+, ❑J PERSON # IVEHICLE; AME DATE OF BIRTH INJ I SEX I LOC: S R O EJECT J 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 W Tranepa 2 EMS 3 Law Enmrcemnrt T] OMer, Evlain in Nanalire 88 Un� ❑ HSMV 90010 S 4 8 Page of _ REPORTING OFFICER ID/BADGE # Reporting Agency Case Number HSMV Crash Report Number NARRATIVE 19-1433 87073116 VEHICLE 1 (UNOCCUPIED) COMPLETELY STOPPED IN TRAFFIC ADJACENT TO 4333 NORTH OCEAN BLVD (S.R. A1A) FACING NORTH. V1 IS A WASTE MANAGEMENT VEHICLE, DRIVER/PASSENGER WERE OUTSIDE OF VEHICLE COLLECTING RECYCLING MATERIAL. CYCLIST S. IRVING WAS RIDING A BICYCLE WITHIN THE NORTHBOUND TRAVEL LANE. FOR UNKNOWN REASON CYCLIST STRUCK THE REAR PORTION OF V1. AT THE SCENE, CYCLIST VERBALLY STATED THAT HE HAD NO EXPLANATION FOR INATTENTIVENESS. ADDITIONAL PASSENGERS OFC PERSON # EHICLE # AME DATE OF BIRTH INJ I SEX I LOCS I R j7CT 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 1NN T,amWa 2 EMS 3 Law Enforcement l) Ol . Ems- in Naea - N U -- ❑ PERSON # VEHICLE # AME DATE OF BIRTH INJ I SEX LOC'. S IR O 1 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 NatTran¢porletl 2 EMS 3 t EntO-M ]] OIM1 Explain in Narrative N Unbrown ❑ ADDITIONAL• • PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER ID/BADGE # RANK OFFICER NAME DEPARTMENTTYPE OF DEPT. POLICE DEPARTMENT I(PD) 750 OFC TODD E. SUTTON GULF STREAM POLICE DEPARTM HSMV 90010 S 5 8 Page of _ DIAGRAM HSMV 90010 S REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 19-1433 1 87073116 6 8 Page of _ NON MOTORIST Of IMPACT Q'D L T y p e R e q u i r e d E n d o r s e m e n t s t A 2 B 3 C Q' 4 D / C h a u f F e u r 1 Y e s 5 E / O p e r a t o r 2 N o 6 E / O p e r - R e s t 3 N o R e q . E n d o r s e m e n t 7 N o n e D r i v e r s A c t i o n s a t T i m e o f C r a s h D i s t r a c t e d B y 4 O t h e r I n s i d e t h e V e h i c l e R e p o r t i n g A g e n c y C a s e N u m b e r ( e x p l a i n i n n a r r a t i v e ) H S M V C r a s h R e p o r t N u m b e r P E R S O N # 2 2 E l e c t r o n i c C o m m u n i c a t i o n ( o u t s i d e t h e v e h i c l e , e x p l a i n D e v i c e s ( c e l l h o n e , e t c . P 1 9 - 1 4 3 3 3 O t h e r E l e c t r o n i c D e v i c e 8 7 0 7 3 1 1 6 1 D r i v e r V E H I C L E # N A M E 8 8 U n k n o w n 6 i m p r o p e r T u m P H O N E N U M B E R C h e c k i f Q' 2 N o n - M o t o r i s t [ Z 2 ] S t e e r i n g I 1 0 F o l l o w e d t o o C l o s e l y N o n - I l o t o r i s l A c t i o n s l G i r c u r r i s l a n c e s ( i n c i d e n t r e s p o n s e ) 4 W a l k i n g / C y c l i n g A l o n g 1 0 N o n e R e c o m m e n d 3 P a s s e n g e r R o a d w a y A g a i n s t T r a f f i c ( i n 7 7 O t h e r , E x p l a i n i n N a r r a t i v e S E N E C Q U E L E V E Q U E Q'1 2 7 8 6 4 4 4 2 8 1 6 D r i v e r R e - e x a m C U R R E N T A D D R E S S ( N u m b e r a n d S t r e e t ) 1 5 I m p r o p e r P a s s i n g R o a d w a y , e t c . E n t e r i n g / E x i t i n g P a r k e d / S t a n d i n g 1 0 I m p r o p e r T u m / M e r g e C I T Y 8 S T A T E Z I P C O D E 3 8 2 1 S E T D R 2 1 W r o n g S i d e o f W r o n g W a y R e c k l e s s o r A g r e e s s i v e M a n n e r ( t a l k i n g , e a t i n g , e t c ) 1 2 W r o n g - W a y R i d i n g o r W a l k i n g L A K E W O R T H F L 3 3 4 6 7 D A T E O F B I R T H S E X . Q' D R I V E R S L I C E N S E N U M B E R S T A T E E X P I R E S I N J U R Y S E V E R I T Y ( I N J ) 4 I n c a p a c i t a t i n g 1 N o n e 5 F a t a l ( w i t h i n 3 0 d a y s ) Q' 1 0 ! 2 4 / 1 9 6 5 2 F e m a l e a l e 8 8 U n k n o w n V E H I C L E # A M E D A T E O F B I R T H I I N J 2 P o s s i b l e 6 N o n - T r a f f i c F a t a l i t y 3 N o n - I n c a p a c i t a t i n g L O C . S Q'D L T y p e R e q u i r e d E n d o r s e m e n t s t A 2 B 3 C Q' 4 D / C h a u f F e u r 1 Y e s 5 E / O p e r a t o r 2 N o 6 E / O p e r - R e s t 3 N o R e q . E n d o r s e m e n t 7 N o n e D r i v e r s A c t i o n s a t T i m e o f C r a s h D i s t r a c t e d B y 4 O t h e r I n s i d e t h e V e h i c l e Q'D r i v e r ( e x p l a i n i n n a r r a t i v e ) 1 N o t D i s t r a c t e d 5 E x t e r n a l D i s t r a c t i o n 2 E l e c t r o n i c C o m m u n i c a t i o n ( o u t s i d e t h e v e h i c l e , e x p l a i n D e v i c e s ( c e l l h o n e , e t c . P i n n a r r a t i v e ) 3 O t h e r E l e c t r o n i c D e v i c e 6 T e x t i n g ( n a v i g a t i o n d e v i c e , D V D p l a y e r ) 7 I n a t t e n t i v e M a r k i n g s 8 8 U n k n o w n 1 s t D r i v e r s A c t i o n s a t T i m e o f C r a s h 5 D e p l o y e d - O t h e r ( k n e e , a i r b e l t , e t c . ) 1 N o t A p p l i c a b l e 6 D e p l o y e d - 2 N o t D e p l o y e d 3 D e p l o y e d - F r o n t 7 D e p l o y e d - C u r t a i n 4 D e p l o y e d - S i d e 8 8 D e p l o y m e n t U n k n o w n N o C o n t r i b u t i o n A c t i o n 2 6 R a n o f f R o a d w a y Q'1 2 O p e r a t e d M V i n C a r e l s s o r 2 7 D i s r e g a r d e d o t h e r T r a f f i c N o n - M o t o r i s t L o c a t i o n A t T i m e o f C r a s h g S i d e w a l k A c t i o n P r i o r t o C r a s h 1 I n t e r s e c t i o n - M a r k e d C r o s s w a l k H 5 W a l k i n g / C y c l i n g o n S i d e w a l k 9 / C r o s s i n g I s l a n d N e g l i g e n t M a n n e r S i g n D r i v e w a y A c c e s s 6 I n R o a d w a y - - O t h e r ( w o r k i n g , D r i v e y e t c . ) 3 F a i l e d t o Y i e l d R i g h t - o f - W a y 2 8 D i s r e g a r d e d O t h e r R o a d S h a r e d - U s e P a t h o r T r a i l 1 C r o s s i n g R o a d w a y p l a y i n g , 4 I m p r o p e r B a c k i n g M a r k i n g s N o n - T r a f f c w a A r e a 7 A d j a c e n t t o R a o d w a y ( e . g . , Y 2 W a i t i n g t o C r o s s R o a d w a y s h o u l d e r , m e d i a n ) 6 i m p r o p e r T u m 2 9 O v e r - C o r r e c t i n g / O v e r W a l k i n g / C y c l i n g A l o n g O t h e r , E x p l a i n i n N a r r a t i v e 3 R o a d w a y 8 G o i n g t o o r f r o m S c h o o l ( K - 1 2 ) ( p a r k e d , e t c . ) S t e e r i n g 2 n d 1 0 F o l l o w e d t o o C l o s e l y N o n - I l o t o r i s l A c t i o n s l G i r c u r r i s l a n c e s ( i n c i d e n t r e s p o n s e ) 4 W a l k i n g / C y c l i n g A l o n g 1 0 N o n e 1 1 R a n R e d L i g h t 3 0 S w e r v e d o r A v o i d e d : D u e R o a d w a y A g a i n s t T r a f f i c ( i n 7 7 O t h e r , E x p l a i n i n N a r r a t i v e D r o v e t o o F a s t f o r C o n d i t i o n s t o W i n d , S l i p p e r y S u r f a c e , M V , Q'1 2 1 3 R a n S t o p S i g n O b j e c t , N o n - M o t o r i s t i n 8 8 U n k n o w n 1 5 I m p r o p e r P a s s i n g R o a d w a y , e t c . E n t e r i n g / E x i t i n g P a r k e d / S t a n d i n g 1 0 I m p r o p e r T u m / M e r g e 1 7 E x c e e d e d P o s t e d S p e e d 3 1 O p e r a t e d M V i n E r r a t i c , 1 1 I m p r o p e r P a s s i n g 2 1 W r o n g S i d e o f W r o n g W a y R e c k l e s s o r A g r e e s s i v e M a n n e r ( t a l k i n g , e a t i n g , e t c ) 1 2 W r o n g - W a y R i d i n g o r W a l k i n g 2 5 F a i l e d t o K e e p i n P r o p e r L a n e 7 7 O t h e r C o n t r i b u t i n g A c t i o n Q' 1 V i s i o n N o t O b s c u r e d 5 L o a d o n V e h i c l e 9 S m o k e 2 I n c l e m e n t W e a t h e r 6 B u i l d i n g / F i x e d O b j e c t 1 0 G l a r e 3 P a r k e d / S t o p p e d V e h i c l e 7 S i g n s / B i l l b o a r d s 7 7 A l l O t h e r , E x p l a i n 4 T r e e s / C r o p s / B u s h e s 8 F o g i n N a r r a t i v e H e l m e t U s e ( H U ) D R I V E R O R P A S S E N G E R 1 : 1 1 D O T - C o m p l i a n t E A T R O W O T H E R M o t o r c y c l e H e l m e t M o t o r V e h i c l e S e a t i n g P o s i t i o n : L O C A T I O N : 2 O t h e r H e l m e t S e a t R o w O t h e r ( L O C ) 3 N o H e l m e t 1 L e f f 1 N o t A p p l i c a b l e 1 F r o n t A i r B a g L 3 r d 4 t h D R I V E R O R P A S S E N G E R C o n d i t i o n A t Q' T i m e o f C r a s h 1 A p p a r e n t l y N o r m a l 3 A s l e e p o r F a t i g u e d 5 I I I ( s i c k ) o r F a i n t e d 6 S e i z u r e , E p i l e s p s y , B l a c k o u t 7 P h y s i c a l l y I m p a i r e d 8 E m o t i o n a l ( d e p r e s s i o n , a n g r y , d i s t u r b e d , e t c . ) 9 U n d e r t h e I n f l u e n c e o f M e d i c a t i o n s / D r u g s / A l c o h o l 7 7 O t h e r , E x p l a i n i n N a r r a t i v e 8 8 U n k n o w n E y e P r o t e c t i o n ( E P ) Q' R e s t r a i n t S y s t e m s Q' 1 Y e s ( R S ) 2 N o 3 N o t A p p l i c a b l e 1 N o t A p p l i c a b l e ( n o n - m o t o r i s t ) 2 N o n e U s e d - M o t o r V e h i c l e O c c u p a n t 3 S h o u l d e r a n d L a p B e l t U s e d e d 4 S h o u l d e r B e l t O n l y U s e d 2 M i d d e 2 S l e e p e r S e c t i o n o f T r u c k C a b 3 R i g h t 2 S e c o n d 9 3 O t h e r E n c l o s e d C a r g o A r e a 7 7 O t h e r 3 T h i r d 4 U n e n c l o s e d C a r g o A r e a ( e x p l a i n i n 4 F o u r t h 5 T r a i l i n g U n i t C o m b i n a t i o n n a r r a t i v e ) 7 7 O t h e r R o w 6 R i d i n g o n M o t o r V e h i c l e E x t e r i o r n o n - 8 8 U n k n o w n 8 8 U n k n o w n ( t r a i l i n g u n i t ) 8 8 U n k n o w n 1 E j e c t i o n E J E C T ( E J E C T ) 1 N o t E j e c t e d Q' 2 E j e c t e d , T o t a l l y 3 E j e c t e d , P a r t i a l l y 4 N o t A p p l i c a b l e 8 8 U n k n o w n 5 D e p l o y e d - O t h e r ( k n e e , a i r b e l t , e t c . ) 1 N o t A p p l i c a b l e 6 D e p l o y e d - 2 N o t D e p l o y e d 3 D e p l o y e d - F r o n t 7 D e p l o y e d - C u r t a i n 4 D e p l o y e d - S i d e 8 8 D e p l o y m e n t U n k n o w n 5 L a p B e l t O n l y U s e d 6 R e s t r a i n t U s e d - T y p e U n k n o w n y P 7 C h i l d R e s t r a i n t S y s t e m - F o r w a r d F a c i n g 8 C h i l d R e s t r a i n t S y s t e m - R e a r F a c i n g 9 B o o s t e r S e a t 1 0 C h i l d R e s t r a i n t T y p e U n k n o w n 7 7 O t h e r , E x p l a i n i n N a r r a t i v e N O N - M O T O R I 9 V S U S P E C T E D D R U G T E S T E D : N ; - M o t o r i s t D e s c r i p t i o n 1 P e ��e s t n a n N o n - M o t o r i s t L o c a t i o n A t T i m e o f C r a s h g S i d e w a l k A c t i o n P r i o r t o C r a s h 1 I n t e r s e c t i o n - M a r k e d C r o s s w a l k H 5 W a l k i n g / C y c l i n g o n S i d e w a l k 9 / C r o s s i n g I s l a n d 2 O t h e r P e d e s t r i a n ( w h e e l c h a r i , p e r s o n i n a 5 b u i l d i n g , s k a t e r , p e d e s t r i a n c o n v e y a n c e , e t c . 2 I n t e r s e c t i o n - U n m a r k e d C r o s s w a l k 1 0 7 7 3 I n t e r s e c t i o n - O t h e r 4 M i d b l o c k - M a r k e d C r o s s w a l k Q' D r i v e w a y A c c e s s 6 I n R o a d w a y - - O t h e r ( w o r k i n g , D r i v e y e t c . ) 3 B i c y c l i s t 1 1 S h a r e d - U s e P a t h o r T r a i l 1 C r o s s i n g R o a d w a y p l a y i n g , 4 O t h e r C y c l i s t 4 M i d b l o c k - M a r k e d C r o s s w a l k 1 2 N o n - T r a f f c w a A r e a 7 A d j a c e n t t o R a o d w a y ( e . g . , Y 2 W a i t i n g t o C r o s s R o a d w a y s h o u l d e r , m e d i a n ) 5 O c c u p a n t o f M o t o r V e h i c l e N o t i n T r a n s p o r t 5 T r a v e l L a n e - O t h e r L o c a t i o n 7 7 6 B i c y c l e L a n e W a l k i n g / C y c l i n g A l o n g O t h e r , E x p l a i n i n N a r r a t i v e 3 R o a d w a y 8 G o i n g t o o r f r o m S c h o o l ( K - 1 2 ) ( p a r k e d , e t c . ) 8 8 7 s h o u l d e r / R o a d s i d e U n k n o w n R o a d w a w i t h T r a f f i c I n o r w i t h y ( 9 W o r k i n g i n T r a f f i c w a y a d j a c e n t t o t r a v e l l a n e ) 6 O c c u p a n t o f a N o n - M o t o r V e h i c l e T r a n s p o r t a t i o n D e v i c e N o n - I l o t o r i s l A c t i o n s l G i r c u r r i s l a n c e s ( i n c i d e n t r e s p o n s e ) 4 W a l k i n g / C y c l i n g A l o n g 1 0 N o n e 7 U n k n o w n T y p e o f N o n - M o t o r i s t 1 N o I m p r o p e r A c t i o n R o a d w a y A g a i n s t T r a f f i c ( i n 7 7 O t h e r , E x p l a i n i n N a r r a t i v e 8 8 U N K N O W N 1 s t 1 2 D a r V D a s h o r a d j a c e n t t o t r a v e l l a n e ) 8 8 U n k n o w n U n k n o w n , i f T e s t e d 3 F a i l u r e t o Y i e l d R i g h t - o f - W a y 8 8 U n k n o w n N o n e S a f e t y E q u i p m e n t 5 L i g h t i n g H e l m e t Q'4 F a i l u r e t o O b e y T r a f f i c S i g n s 1 I �� S i g n a l s , o r O f f i c e r 7 E n t e r i n g / E x i t i n g P a r k e d / S t a n d i n g 1 0 I m p r o p e r T u m / M e r g e 6 N o t A p p l i c a b l e S P r o t e c t i v e P a d s U s e d 7 7 O t h e r , E x p l a i n 2 n d l 5 I n R o a d w a y I m p r o p e r t y ( s t a n d i n g , V e h i c l e 1 1 I m p r o p e r P a s s i n g e l b o w s , k n e e s , s h i n s , e t c . ) i n N a r r a t i v e L ��J l y i n g , w o r k i n g , p l a y i n g ) 8 I n a t t e n t i v e ( t a l k i n g , e a t i n g , e t c ) 1 2 W r o n g - W a y R i d i n g o r W a l k i n g I R e f l e c t i v e C l o t h i n g ( j a c k e t , 8 8 U n k n o w n Q' 6 D i s a b l e d V e h i c l e R e l a t e d ( w o r k i n g 9 N o t V i s i b l e ( d a r k c l o t h i n g , n o 7 7 O t h e r , E x p l a i n i n N a r r a t i v e ) a c k p a c k , e t c . ) o n , p u s h i n g , l e a v i n g / a p p r o a c h i n g ) l i g h t i n g , e t c . ) 8 8 U n k n o w n A l m u n i 1 n i 2 u r a 1 9 : U Q S U S P E C T E D A L C O H O L T E S T E D . A L C O H O L T E S T T Y P E : A L C O H O L B A C S U S P E C T E D D R U G T E S T E D : D R U G T E S T T Y P E : D R U G T E S T R E S U L T . A L C O H O L U S E : Q' 1 N o 1 1 T e s t N o t G i v e n Q' 2 T e s t R e f u s e d 1 B l o o d 2 B r e a t h Q'T E S T 3 U r i n e 1 P E N D I N G R E S U L T F - 1 1 1 1 D R U G U S E : 1 1 N o 2 T e s t N o t G i v e n Q' T e s t R e f u s e d 1 U B l o o d n n e 3 U r i n e 1 P o s i t i v e 2 N e g a t i v e Q' 2 Y e s 3 T e s t G i v e n 7 7 O t h e r , E x p l a i n 2 C O M P L E T E D 2 Y e s 3 T e s t G i v e n 7 7 O t h e r , 3 P e n d i n g 8 8 U n k n o w n 8 8 U n k n o w n , i f T e s t e d i n N a r r a t i v e 8 8 U N K N O W N 8 8 U n k n o w n 8 8 U n k n o w n , i f T e s t e d E x p l a i n i n N a r r a t i v e 8 8 U n k n o w n S O U R C E O F T R A N S P O R T T O M E D I C A L F A C I L I T Y E M S A G E N C Y N A M E O R I D E M S R U N N U M B E R M E D I C A L F A C I L I T Y T R A N S P O R T E D T O 1 N o t T r a n s p o r t e d 2 E M S 3 L a w E n f o r c e m e n t 1 7 7 O t h e r , E x p l a i n i n N a r r a t i v e 8 8 U n k n o w n A D D I T I O N A L P A S S E N G E R S P E R S O N # V E H I C L E # A M E D A T E O F B I R T H I I N J S E X L O C . S I R 0 E J E C T H U E P A B D R S C U R R E N T A D D R E S S ( N u m b e r a n d S t r e e t ) C I T Y S T A T E Z I P C O D E S O U R C E O F T R A N S P O R T T O M E D I C A L F A C I L I T Y E M S A G E N C Y N A M E O R I D E M S R U N N U M B E R M E D I C A L F A C I L I T Y T R A N S P O R T E D T O 1 N a T r z m p o r 2 E M S 3 1 E n r o r M 7 7 p r i e r , E x p l a i n i n N a r a U u e 8 8 U n Q' P E R S O N # V E H I C L E # A M E D A T E O F B I R T H I N J S E X L O C - . S R 0 E J E C T H U E P A B D R S C U R R E N T A D D R E S S ( N u m b e r a n d S t r e e t ) C I T Y S T A T E Z I P C O D E S O U R C E O F T R A N S P O R T T O M E D I C A L F A C I L I T Y Q' E M S A G E N C Y N A M E O R I D E M S R U N N U M B E R M E D I C A L F A C I L I T Y T R A N S P O R T E D T O t N o t T r e n s P m w 2 E M S 3 L a v E l i n a f t e r , E x p l a i n i n N a r r a l i r e 8 8 U n k n o w n H S M V 9 0 0 1 0 S 7 8 P a g e o f PERSON # 3 1 Driver VEHICLE # NAME 2 Non -Motorist a I 3 Passenger MURANO CURRENT ADDRESS (Number and Street) 27 Disregarded other Traffic 6054 BLUE STONE LN Recommend DATE OF BIRTH SEX: Driver Re-exam CITY 8 STATE DRIVERS LICENSE LAKE WORTH FL 1 Mate 1BER 1 ❑ EXPIRES INJURY SEVERITY (INJ) 4 Incapacitating 2 Female Steering 2nd 10 Followed too Closely 01/0611960 88 Unknown 11 Ran Red Light 30 Swerved or Avoided : Due 1 DOT -Compliant ❑DL Type 1A263C Required Endorsements ❑ 4 D/Chauffeur 1 Yes Object, Non -Motorist in 5 E/Operator 2 No Roadway, etc. 6 E/Oper-Rest 3 No Req. Endorsement 7 None 21 Wrong Side of Wrong Way Reckless orAgreessive Manner Driver Distracted By 4 Other Inside the Vehide ❑ (explain in narrative) 1 Not Distracted 5 External Distraction 2 Electronic Communication (outside the vehicle, explain Devices (cell phone, etc. in narrative) 3 Other Electronic Device 6 Taxiing (navigation device, DVD player) 7 Inattentive EHICLE # 88 Unknown Reporting Agency Case Number HSMV Crash Report Number 19-1433 87073116 26 Ran off Roadway PHONE NUMBER Check if ❑ 27 Disregarded other Traffic 77 Recommend ENEJUSTE 5616474000 Driver Re-exam CITY 8 STATE ZIP CODE LAKE WORTH FL 1 33463 1BER STATE EXPIRES INJURY SEVERITY (INJ) 4 Incapacitating 3 Bicyclist 4 Other Cyclist Steering 2nd 10 Followed too Closely 1 None 5 Fatal (within 30 days) 2 Possible ❑ 11 Ran Red Light 30 Swerved or Avoided : Due 1 DOT -Compliant 3 Non -Incapacitating 6 Non -Traffic Fatality to Wind, Slippery Surface, MV, 1st Drivers Actions at Time of Crash Non -Motorist Location At Time of Crash 1 Intersection -Marked Crosswalk No Contribution Action 26 Ran off Roadway ❑1 2 Operated MV in Carelss or 27 Disregarded other Traffic 77 Negligent Manner Sign 1 Blood 2 Breath❑TEST 3 Urine 3 Failed to Yield Right -of -Way 28 Disregarded Other Road building, skater, pedestrian conveyance, etc. 4 Improper Backing Markings 11 Shared -Use Path or Trail 6 Improper Turn 29 Over-Correcting/Over 4 Trees/Crops/Bushes 8 Fog in Narrative 3 Bicyclist 4 Other Cyclist Steering 2nd 10 Followed too Closely 2 Waiting to Cross Roadway Systems 11 Ran Red Light 30 Swerved or Avoided : Due 1 DOT -Compliant Drove too Fast for Conditions to Wind, Slippery Surface, MV, ❑12 13 Ran Stop Sign Object, Non -Motorist in EAT ROW 15 Improper Passing Roadway, etc. in 9 Working in Trafficway 17 Exceeded Posted Speed 31 Operated MV in Erratic, Motor Vehicle 21 Wrong Side of Wrong Way Reckless orAgreessive Manner (incident response) 25 Failed to Keep in Proper Lane 77 Other Contributing Action 3rd 1-1 4th 11 Condition At ❑ Time of Crash I Apparently Normal 3 Asleep or Fatigued 5 III (sick) or Fainted 6 Seizure, Epilespsy, Blackout 7 Physically Impaired 8 Emotional (depression, angry, disturbed, etc.) 9 Under the Influence of Medications/Drugs/Alcohol 77 Other, Explain in Narrative 88 Unknown N n -Motorist Description 1 Per�estnan 1 Vision Not Obscured 5 Load on Vehicle 9 Smoke Non -Motorist Location At Time of Crash 1 Intersection -Marked Crosswalk 8 Sidewalk 9 Median/Crossing Island 1 ❑ TESTED: 2 Inclement Weather 6 Building/Fixed Object 10 Glare 77 DRIVER OR PASSENGER 10 Driveway Access 1 Blood 2 Breath❑TEST 3 Urine 3 Parked/Stopped Vehicle 7 Signs/Billboards 77 All Other, Explain $ ❑ building, skater, pedestrian conveyance, etc. ❑ 3 Intersection - Other4 Midblock - Marked Crosswalk 11 Shared -Use Path or Trail 1 Crossing Roadway playing, etc.) 4 Trees/Crops/Bushes 8 Fog in Narrative 3 Bicyclist 4 Other Cyclist Helmet Use (HU) 4 Midblock - Marked Crosswalk Eye Protection (EP)F1Restraint 2 Waiting to Cross Roadway Systems 5 Occupant of Motor Vehicle Not in Transport DRIVER OR PASSENGER 1 DOT -Compliant 1 Yes 3 Along (RS) (parked, etc-) Explain in Narative EAT ROW OTHER Motorcycle Helmet in 9 Working in Trafficway 2 No 1 Not Transported Motor Vehicle Seating Position: LOCATION: (incident response) Transportation Deviceon- 7 Unknown Type of Non -Motorist 77 Other, Explain in Narrative 88 Unknown o ons c ions mums ances 1 No Improper Action 2 Other Helmet Roadway Against Traffic (in 3 Not Applicable 1 NotApplicable (non -motorist) ADDITIONAL tst� (LOC) 2 Dart/Dash EHICLE # or adjacent to travel lane) 88 Unknown INJ SEX 3 No Helmet IR 3 Failure to Yield Right -of -Way 2 None Used - Motor Vehicle Occupant Seat Row Other 1 None Safety Equipment 5 Lighting 2 Helmet 6 Not Applicable I RS 4 Failure to Obey Traffic Signs Signals, or Officer 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge 3 Protective Pads Used ZIP CODE 2 Roadway improperly Vehicle 3 Shoulder and Lap Belt Used 1 Left 2 Middle1 1 Not Applicable Front 2 Sleeper Section of Truck Cab Air Bag Deployed 5 Deployed -Other 4 Shoulder Belt Only Used 5 La Belt OnlyUsed 3 Right 2 Second 3 Other Enclosed Cargo Area Ejection (EJECT)(knee, ❑ air belt, etc.) 6 Restraint Used -Type Unknown 77 Other 3 Third 4 Unenclosed Cargo Area 1 Not Ejected backpack, etc.) 1 Not Applicable 6 Deployed- 7 Child Restraint System - Forward Facing (explain in 4 fourth 5 Trailing Unit 2 Ejected, Totally CITY 2 Not Deployed Combination 8 Child Restraint System - Rear Facing narrative) 88 Unknown 77 Other Row 6 Riding on Motor Vehicle Exterior (non- 3 E jetted, Partially MEDICAL FACILITY TRANSPORTED TO 3 Deployed -Front 7 Deployed -Curtain 4 Deployed -Side 9 Booster Seat 10 Child Restraint Type Unknown 88 Unknown trailing unit) 4 Not Applicable USknopvinyment 77 Other, Explain in Narrative 88 Unknown 88 Unknown N n -Motorist Description 1 Per�estnan ALCOHOL TESTED: Non -Motorist Location At Time of Crash 1 Intersection -Marked Crosswalk 8 Sidewalk 9 Median/Crossing Island Action Prior to Crash 77 Walking/Cycling on Sidewalk 5 Watkin / TESTED: 2 Other Pedestrian (wheelchan, person in a 77 2 Intersection - Unmarked Crosswalk 10 Driveway Access 1 Blood 2 Breath❑TEST 3 Urine 6 In Roadway Other (working, y – $ ❑ building, skater, pedestrian conveyance, etc. ❑ 3 Intersection - Other4 Midblock - Marked Crosswalk 11 Shared -Use Path or Trail 1 Crossing Roadway playing, etc.) 77 Other, Explain 3 Bicyclist 4 Other Cyclist 4 Midblock - Marked Crosswalk 12 Non-Trafficway Area 2 Waiting to Cross Roadway 7 Adjacent to ion)Raoy (e.g., median) 5 Occupant of Motor Vehicle Not in Transport 88 Unknown, if Tested 5 Travel Lane - Other Locationshoulder, 6 Bicycle Lane Y 77 Other, Explain in Narrative 88 3 Along 8 Going to from School (K-12) (parked, etc-) Explain in Narative 7 shoulder/Roadside Unknown withWalking/Cycling Traffic Roadway with Traffic (in or Roadway adjacent to travel lane) in 9 Working in Trafficway 6 Occupant of a Non -Motor Vehicle 1 Not Transported 4 Walking/Cycling Along (incident response) Transportation Deviceon- 7 Unknown Type of Non -Motorist 77 Other, Explain in Narrative 88 Unknown o ons c ions mums ances 1 No Improper Action Roadway Against Traffic (in 10 None 77 Other, Explain in Narrative ADDITIONAL tst� 2 Dart/Dash EHICLE # or adjacent to travel lane) 88 Unknown INJ SEX LOC' S IR 3 Failure to Yield Right -of -Way EJECT J HU EP 1 None Safety Equipment 5 Lighting 2 Helmet 6 Not Applicable I RS 4 Failure to Obey Traffic Signs Signals, or Officer 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge 3 Protective Pads Used ZIP CODE 2 Roadway improperly Vehicle 11 Improper Passing t NU Trane M 2 EMS S- Enfaccment 77OINer, Explain In Nan_ N J- 77 Other, Explain (elbows, knees, shins, etc.) 5 In (standing, lying, working, playing) 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking in Narrative 4 Reflective Clothing (jacket, 88 Unknown ❑ INJ SEX 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative backpack, etc.) HU I on, pushing, leaving/approaching) lighting, etc.) 88 Unknown CURRENT ADDRESS (Number and Street) CITY STATE At rnwni /nRiir1FMS SOURCE OF TRANSPORT TO MEDICAL FACILITY AGENCY NAME OR ID SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: ALCOHOL BAC SUSPECTED DRUG TESTED: DRUG TEST TYPE 1DRUG TEST RESULT: ALCOHOL USE: ❑ 1 No 1 1 Test Not Given 2 Test Refused 1 Blood 2 Breath❑TEST 3 Urine RESULT: ❑ 1 PENDING ❑ DRUG USE: 1 1 No 2 Test Not Given Test Refused ❑ 1 Blood 3 Urine [:]3 1 Positive 2 Negative ❑ 1 2 Yes 3 Test Given 77 Other, Explain 2 COMPLETED 2 Yes 3 Test Given 77 Other, Pending 88 Unknown 88 Unknown, if Tested in Narrative 88 UNKNOWN 88 Unknown 88 Unknown, if Tested Explain in Narative 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 # EHICLE # AME DATE OF BIRTH I INJ SEX LOC' S IR O EJECT J HU EP 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 t NU Trane M 2 EMS S- Enfaccment 77OINer, Explain In Nan_ N J- PERSON # VEHICLE # AME DATE OF BIRTH I INJ SEX ILOC:S IR O 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 AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO I Not haneporteE 2 EMS 3 law Enlacement 77 Otho. 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