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HomeMy Public PortalAboutPRR 19-2756 TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered in-person November 26, 2019 Pavret Wilson RE: GS #2756 (Request for Crash Report on 11/15/19 – Case Number 19-2175) Pavret is requesting Crash Report on 11/15/19 – Case Number 19-2175. Dear Pavret Wilson: The Town of Gulf Stream has received your public records requests dated November 22, 2019. You should be able to view your original request and response at the following link, as of January 20, 2020, due to the record’s status as confidential and exempt from disclosure for a period of 60 days after the crash report is filed per Florida Statute 316.066(2)(a): http://www2.gulf-stream.org/weblink/0/doc/168768/Page1.aspx The police crash report you requested is available to be picked up at Town Hall any time between the office hours of 8:00 AM and 4:00 PM. We consider this request closed. Sincerely, Reneé Rowan Basel As requested by Rita Taylor Town Clerk, Custodian of the Records FLORIDA TRAFFIC CRASH REPORT WAS DOT PROPERTY INVOLVED IN THIS CRASH? LONG FORM ❑ SHORT FORM ❑ UPDATE Q TOTAL # OF VEHICLE SECTION(S) 1 (Shaded Areas) 2 TOTAL # OF PERSON SECTION(S) MAIL TO: DEPARTMENT OF HIGHWAY SAFETY & MOTOR VEHICLES 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 11/15/2019 4:40 PM 11/25/2019 119-2175 187073119 CRASH IDENTIFIERS COUNTY CODE Weather Condition AT STREET ADDRESS # PLACE OR CITY OF CRASH CHECK IF WITHIN IME REPORTED TIME DISPATCHED 06 ICITYCODE 44 ICOUNTYOFCRASH PALM BEACH GULF STREAM CITY LIMITS 14:45 PM 1 4:45 PM TIME ON SCENE N S IME CLEARED SCENE CHECK IF REASON (If Investigation NOT Complete) 4 Dark -Lighted Noted By. 1 Motorist 72 (standing/moving) 16:15 COMPLETED O LITTLE CLUB RD 2 4:46 PM Road System Identifier PM 1 Front to Type of Shoulder 2 Law Enforcement ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAY Weather Condition AT STREET ADDRESS # School Bus Related © AT LATITUDE AND LONGITUDE S.R. AIA (N. OCEAN BLVD) 5 Dark -Not Lighted 6Dark-Unknown 4 Flog, Smog, Smoke 5 Sleet/Hail/ 3 Freezing Rain ❑ 5 Oil 6 Mud, Dirt, Gravel 7 Sand 1 No 2 Yes, School Bus 26.503755 -80.053471 AT FEET MILES N S E W ATIFROM INTERSECTION WITH STREET, ROAD,HIGHWAYOR 6 Rear to Side 4 Dark -Lighted FROM MILEPOST # a 72 (standing/moving) 11:1 0 El 1:1© LITTLE CLUB RD Narrative 1 Clear 7 Severe Crosswinds Road System Identifier 7 Forest Road 1 Front to Type of Shoulder TVDe of Intersection 5 Traffic Circle ❑1 Interstate 4 County 3 2 U.S. 5 Local 8 Private Roadway 9 Parking Lot 1 Paved 2 Unpaved 1 3 Rain Narrative 1 Nof at Intersection 2 Four -Way Intersection 3 T -Intersection 6 Roundabout 7 Five -Point, or More 77 Other, Explain in Narrative 3 State 6 Tumpike/Toll 77 Other, Explain in Narrative 3 Curb First Harmful Event 4 Y -Intersection CRASH INFORMATION (CHECK IF PICTURES TAKEN) .i 2 Fire/Explosion 11 Pedalcycle 31 3 Immersion 12 Railway vehicle (train, 20 Bridge Overhead Structure 32 Tree (standing) 2 Oft Roadway Light Condition Weather Condition Roadway Surface Condition School Bus Related NAME Manner of Collision/Impact 1 Daylight 1 2 Dusk 5 Dark -Not Lighted 6Dark-Unknown 4 Flog, Smog, Smoke 5 Sleet/Hail/ 3 Freezing Rain ❑ 5 Oil 6 Mud, Dirt, Gravel 7 Sand 1 No 2 Yes, School Bus 4 Sideswipe, same direction 5 Sideswipe, Opposite Direction 3 Dawn Lighting 6 BlowingSand, Soil 2 8 Water ❑ 1 Direct/ Involved ❑ y MONUMENT SIGN 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 Overtum/Rollover 10 Pedestrian 19 Impact Attenuator/Crash 30 Concrete Cusion Other Traffic Barrer Location 1 On Roadway 2 Fire/Explosion 11 Pedalcycle 31 3 Immersion 12 Railway vehicle (train, 20 Bridge Overhead Structure 32 Tree (standing) 2 Oft Roadway 33 4 Jackknife engine) 21 Bridge Pier or Support 33 Utility Pole/Light Support 3 Shoulder 5 Cargo/Equipment 13 Animal 22 Bridge Rail 34 Traffic Sign Support 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 7 Thrown or Falling 16 Work Zone/Maintainance 26 Embankment 37 Fence Zone 1 No 2 Yes Object Equipment 27 Guardrail Face 38 Mailbox 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 buildinq, tunnel, etc.) 88 Unknown 18 Other Non -Fixed Ob-ect First Harmful Event Relation to Contributing Circumstances: Road g Wom, Travel -Polished Surface Contributing Circumstances: Environment 77 Junction 5 Railway Grade Crossing 14 Entrance/Exit Ramp 10 Raod Surface Condition (wet, i icy, snow, slush, etc.) ❑ 11 Obstruction in Roadway 1 Non -Junction 15 15 Crossover - Related 16 Shared -Use of Path or Trail 12 Debris None 13 Traffic Control Device 1 None 5 Animals in Roadway O Y 2 Intersection 17 Acceleration/Dceleration Lane 4 Work Zone (construction/ Inoperative, Missing or Obscured P 9 2 Weather Conditions 77 Other, Explain in 3 Intersection -Related 18 Through Roadwaymaintenance/utility 14 Non -Highway Work 3 Physical Obslruction(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 Zone 1 No 1 2 Yes 117 Warring Sign 2Advance Warning Area ❑ 3 Transition Area 2 Lane Shif /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 TNESSES NAME ANGELA LYNN SANTINO ADDRESS 3851 N OCEAN BLVD CITY & STATE GULFSTREAM ZIP CODE FL 33483 NAME ADDRESS CITY & STATE ZIP CODE NAME ADDRESS CITY & STATE ZIP CODE NON VEHICLE PROPERTY DAMAGE EST AMT. OWNER'S NAME 2] (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE 1 VEH. # PER # PROPERTY DAMAGE -OTHER THAN VEH. EST AMT. OWNER'S NAME 2] (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE 1 (UTILITY POLE OR LIGHT POLE) 5000 BOYNTOPOLE FLORIDA POWER AND LIGHT COMPANY 9329 S MILITARY TRAIL BEACH N FL 33436 VEH. # PER # PROPERTY DAMAGE -OTHER THAN VEH. EST AMT. OWNER'S NAME 2] (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE 1 MONUMENT SIGN 5000 TOWN OF GULF STREAM 100 SEA RD GULF STREAM FL 33483 HSMV 90010 S 1 5 Page of _ VEHICLE # 1 Check if Commercial Reporting Agency Case Number HSMV Crash Report Number ❑ 19-2175 1 87073119 1 Vehiclein Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES VIN 2 Parked Motor Vehicle 1 Check d Permanent 3 Working Vehicle EAJJ57 FL 06/13/2020 Registration [:] 2T3H1 RFV4KW040992 Hit and Run YEAR MAKE MODEL STYLE COLOR DAMAGE: EST. AMOUNT 1 No 1 Disabling 4 Minor 2 Yes 2019 TOYT RAV4 UTILITY GRAY - GRY 2 Functional 88 Unknown 3 None 88 Unknown 1 $10,000.00 INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due VEHICLE REMOVED BY 1. Rotation to Damage: 2. Owner Request a GEICO INDEMNITY COMPANY 4446926977 2UCCALAS TOWING 3. Driver 1 No 2 Yes 14. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ CURRENT ADDRESS CITY & STATE ZIP ELOURDES NMN CASEUS 1643 NW 11TH CIRCLE POMPANO BEACH FL 33069 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if 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 TOTAL LANES TRAVELING R ❑ ❑ ❑ ❑ ❑ S.R.A1A N. OCEAN BLVD 130 35 2 HAZ. MAT. RELEASED HAZ. MAT. PLACARD NUMBER CLASS Area of Initial Impact Most Damaged Area Yeo ❑ 1 No ❑ 3 4 5 6 14 01 #345#6 2 Yes 2Yes 2 7 18 Undercarriage 18 88 Unknown 88 Unknown 19 Ovenum 19MOTOR CARRIER NAME US DOT NUMBER 1 15 16 17 6 20 Windshield 2014 13 1211 0 9 21 Trailer 2t MOTOR CARRIER ADDRESS CITY STATE I ZIP CODE PHONE NUMBER Vehicle Body Type 15 Law Speed Vehicle Traffrcway Commercial Motor Vehicle Configuration 16 (Sport) Utility Vehicle 1 Two -Way, Not Divided 1 Vehicle 10,000 lbs or less Placarded 8 Tractor/rriple 1 for Hazardous Materials 9 Truck more than 10,000 lbs (4,536 16 17 Cargo Van (t0,0001bs 2 Two- Way, Not Divided, with a 4,536 k or less Continuous Lefl Tum Lane 2 Single -Unit Truck (2 -axle and GVWR kg), Cannot Classify ( g) ) more than 10,000 lbs (4,536 kg)) 10 Bus/Large van (seats for 9-15 1 Passenger Car 18 Motor Coach 3 Tyro -Way, Divided, Unprotected occupants, including driver 2 Passenger Van 19 Other Light Tricks (10,000 lbs (painted >4 feet) Median 3 Single -Unit Truck er or more axles) Pa 9 ) 4 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) 6 Truck Tractor/occupants, including driver) Doubl Trailer 77 Other, Explain in Narrative Bus than 10,000 lbs (4,536 kg)) 5 One -Way Trafficway 7 Truck Tractor/Double Truck 88 Unknown 11 Motorcycle 21 Farts Labor Vehicle 88 Unknown Trailer Type 12 Moped 77 Other, Explain in NarrativeTrailer Single Sei Trailer 8 Pole Trailer 13 All Terain Vehicle (ATV) 68 Unknown 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type 13 Internodal Comm/Non-Commercial TRAILER 1 TRAILER 2 3 Tank Trailer 10 Auto Transport 4 Saddle Mount/Trailer 77 Other, Explain in 3 Van/EnHopper Box Container Chassis ❑ 1 Interstate Cartier ❑ ❑ ❑ 4 Hopper An Vehicle Towing 5 Boat Trailer Narrative 2 Intrastate Cartier SPole-Trailer Another Vehicle 6 Utility Trailer 88 Unknown 3 Not in Commerce/Government 7 House Trailer 1 No Cargo 6 Cargo Tank 15 Not Applicable 4 Not in Commerce/Other Truck 2 Bus 7 Flatbed (vehicle 10,000 lbs Most Harmful Event Non -Collision Comm ❑ 1 10,000 lbs (4,536 kg) or less 8 Dump displaying kg) or less not 1 Overtum/Rollover GVWR/GCWR 4 2 More 1-26,000lbs00 lbs III1,793kg) 9 Concrete Mixer displaying xp 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 39 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 20 BridImpge OvAtterhead Structure Cushion 30 Concrete Traffic Barrier Vehicle Use 20 Bridge Overhead Structure 7 Thrown or Falling Object 12 Railway Vehicle (train, engine) 31 Other Traffic Barrier 21 Bridge Pier or Support Sequence of Events 8 Ran into Water/Canal 13 Animal 32 Tree (standing) 22 Bridge Rail 1 9 Other Non -Collision 14 Motor Vehicle in Transport 23 Culvert 33 Utility Pole/Light Support 1st 2nd 15 Parked Motor Vehicle 34 Traffic Sign Support 140-46 Sequence of Events only] 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 43 33 40 equipment Failure (blown tire, Equipment 25 Ditch 36 Other Post, Pole, or Support 1 No brake failure, etc.) 17 Stack By Falling, Shifting Cargo or 26 Embankment 37 Fence 2 Yes 41 Separation of Units Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox 88 Unknown 3rd 4th 42 Ran Off Roadway, Right Vehicle 28 Guardrail End 39 Other Fixed Object (wall, 39 ❑ 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 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 1 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 Sigh 3 Tires Windshield Windows/ 4 Downhill 1 Straight 8 Parked 77 011ier. Explain in Narrative 10 Person (including Device 4 Lights (head, 16 Mirrors 5 Sag (bottom) 1 2 Curve Right 10 Making U -Tum 88 Unknown Flagman, Officer, 3 Curve Left 11 Overtaking/Passing 5 Traffic Control Guard, etc.) signal, tail) 15 Mirors Signal 6 Steering 16 Truck Coupling Special Function 1 No Special Other, Explain in al Function 9 Ambulance 14 Intercity Bus 6 Stop Sign 7 Wipers Trailer Hitch/ 2 Farm Vehicle 1 S 0 Fire Truck 15 hour Bus 7 Yield Sign NaNarrative9 Exhaust System Safety Chains of Motor Vehicle EE 3 Police 11 Farm Labor Transport 16 Shuttleuttle Bus 88 Unknown 10 Body, Doors 77 Other, Explain in 7 Taxi 12 School Bus 17 Farm Labor Bus 11 Power Train Narrative 8 Military 13 TransitlCommuter 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 5 Page of_ HSMV 90010 S 3 5 Page of Reporting Agency Case Number HSMV Crash Report Number PERSON # 1 19-2175 87073119 1Driver VEHICLE# NAME PHONE NUMBER heck 'rf El3 2 Non-Motorist 1 ❑ Recommend Passenger 1 WILSON NMN PAVRET (954) 343.4554 Driver Re-exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 1543 NW 11TH CIR APT N69 POMPANO BEACH FL 33069 DATE OF BIRTH SEX: 1 Male DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4 Incapacitating 1 None 5 Fatal (within days) 2 05/15/1965 2 Female 88 Unknown P163880651750 FL 05/1512021 2 Possible at 3 Non-Incapacitating 6Non-Traffic Fatality DL Type Required Endorsements list Drivers Actions at Time of Crash 3rd Condition At ❑ 1 A 2 B 3 C1 No Contribution Action 26 Ran off Roadway Time of 6 4 D/Chauffeur 3] 1 Yes 26 2 Operated MV in Carelss or 27 Disregarded other Traffic 25 Crash Negligent Manner Sign 151 5 E/Operator 2 No 1 Apparently Normal 6 E/0per-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 III (sick) or Fainted 6 Improper Tum 29 Over-Correcting/Over5 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 1 Not Distracted 5 Extemal Distraction 11 Ran Red Light 30 Swerved or Avoided Due 8 Emotional (depression, 4th angry, disturbed, etc.) 2 Electronic Communication (outside the vehicle, explain 12 Drove too Fast for Conditions to Wind, Slippery Surface, MV. 9 Under the Influence of 77 Devices cell hone, etc. ( P in narative) 13 Ran Stop Sign Object, Non-Motorist in Medications/Drugs/Alcohol H 3 Other Electronic Device 6 Texting 15 Improper Passing Roadway, etc. 77 Other, Explain in Narrative (navigation device, DVD player) 7 Inattentive 17 Exceeded Posted Speed 31 Operated MV in Eratic, 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 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 All Other, Explain ❑ 4 Trees/Crops/Bushes 8 Fog in Narrative Helmet Use (HU) Eye Protection (EP) Restraint Systems 1 DOT-Com leant 1 Yes 3 (RS) DRIVER OR PASSENGER ❑ P ❑ SEAT ROW OTHER Motorcycle Helmet 2 No Motor Vehicle Seating Position: LOCATION-. 2 Other Helmet 3 Not Applicable 1 NolApplicable (non-motorist) (LOC) 1 1 1 3 No Helmet 2 None Used - Motor Vehicle Occupant Seat Row Other 3 Shoulder and Lap Belt Used 1 Left 1 Not Applicable 4 Shoulder Belt Only Used 1 Front Air Bag Deployed 5 Lap Belt Only Used 2 Midde 2 Sleeper Section of Truck Cab 5 Deployed-Other 3 Right 2 Second 3 Other Enclosed Cargo Area Ejection (EJECT) (knee, air belt, etc.) 6 Restraint Used - Type Unknown 1 Not Ejected ❑ 1 Not Applicable 6 Deployed- 7 Child Restraint System -Forward Facing 77 Other 3 Third 4 Unenclosed Cargo Area 3 (explain in 4 Fourth 2 Ejected, Totally 2 Not Deployed 8 Child Restraint System -Rear Facing 5 Trailing Unit 1Combination g ❑ narrative) 77 Other Row 3 Ejected, 3 Deployed-Front 7Deployed-Curtain 9 Booster Seat 88 Unknown 6 Riding on Motor Vehicle Exterior (non- Partially 4 Deployed-Side 10 Child Restraint Type Unknown 8B Unknown trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown NON- N n-Motorist Description Non-Motorist Location At Time of Crash 8 Sidewalk Action Prior to Crash 1 Pedestrian 1 Intersection - Marked Crosswalk ❑ 5 Walking/Cycling on Sidewalk ❑ ❑ 9 MediaNCrossing Island 2 Other Pedestrian (wheelchan, person in a 2 Intersection - Unmarked Crosswalk 10 Driveway Access 6 In Roadway -- Other (working, building, skater, pedestrian conveyance, etc. 3 Intersection - Other4 Midblock - Marked Crosswalk playing, etc.) 11 Shared-Use Path or Trail 1 Crossing Roadway 3 Bicyclist 4 Midblock - Marked Crosswalk 7 Adjacent to Raodway (e.g., 12 Non-Trafficway Area 2 Waiting to Cross Roadway 4 Other Cyclist shoulder, median) 5 Travel Lane -Other Location 77 Other, Explain in Narrative 3 Walking/Cycling Along 5 Occupant of Motor Vehicle Not in Transport 6 Bicycle Lane 8 Going to or from School (K-12) 88 Unknown (parked, etc.) 7 shoulder/Roadside Roadway with Traffic (in or g Working in Traffcway 6 Occupant of a Non-Motor Vehicle adjacent to travel lane) (incident response) Transportation Device on- o ons c ons rrcums ances 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 1st ❑ 2 Dart/Dash or adjacent to travel lane) 88 Unknown 3 Failure to Yield Right-of-Way 1 None Safety Equipment 5 Lighting 4 Failure to Obey Traffic Signs 2 Helmet 6 NotApplicable Signals, or Officer 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge 3 Protective Pads Used Vehicle 11 Improper Passing 9gn. 77 Other, Explain 5 In Roadway Improperly (standing, knees, 8 Inattentive (talking, eating, etc) 12 Wrong-Way Riding or Walking (elbows, shins, etc.) in Narrative lying, working, playing) 4 Reflective Clothing (jacket, 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative 88 Unknown ( 9 backpack, etc.) on, pushing, leavin /a lighting. etc.) 88 Unknown p p g, g pproaching) ALCOHOUDRUG/EMS SUSPECTED ALCOHOL TESTED. ALCOHOL TEST TYPE: LCOHOL BAC SUSPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT. 2 YeOHOL USE. ❑ 1 No 1 1 Test Not Given ❑ 2 Test Refused 1 Blood 2 Breath ❑ 3 Urine EST RESULT: ❑ 1 PENDING DRUG USE: 1 1 No ❑ 2 1 Test Not Given ❑ Test Recused 1 Blood ❑ 3 Urine 1 Positive 2 Negative 3 Test Given 77 Other, Explain 2 COMPLETED Yes 3 Test Given 77 Other, 3 Pending 88 Unknown 88 Unknown, tt 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 Enforcement2 BOYNTON BEACH FIRE DEPARTMENT BBFD 19012370 DELRAY MEDICAL CENTER 77 Other, Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON # VEHICLE #[AME DATE OF BIRTH INJ J 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 1 Nd TrznspoN M 2 EMS 3 Law EnlmcemeM 77 Ot—, E Wain in `,—t re W U­ ❑EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO PERSON # VEHICLE # AME DATE OF BIRTH I INJ I SEX I LOC. S I R 0 EJECT I HU I EP I 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 NdT, 1po 2 EMS 31r Enrwmmed 77 Olhm. E4M'1 in NartalNe aB Unkr,oxn ❑ HSMV 90010 S 3 5 Page of ADDITIONAL VIOLATIONS PERSON # Reporting Agency Case Number HSMV Crash Report Number NARRATIVE 19-2175 87073119 Vehicle 1 traveling northbound in the 4400 block of North Ocean Blvd, ( State Road AIA). In the 4400 block Vehicle 1 left the roadway crossing into the South bound lane and then into the grass on the west shoulder of the roadway. Vehicle 1 continued traveling north in the grass and side swiped a hedge and then crashed into a Florida Power and Light power pole . After crashing into the FPL pole ,causing structure damage to the pole, the vehicle was propelled north bound into a cement block holding the Town of Gulf Stream sign. The sign was heavily damaged . The vehicle then did a 360 degree tum and came to rest facing west in the exit road for Little Club Road. Boynton Beach Fire rescue extracted the driver from the vehicle and he was found to be suffering from (77) Diabetic seizure which had caused him to lose consciousness while driving. Driver sustained minor bruising and lacerations from the air bag deployment. No other vehicles involved. ADDITIONAL PASSENGERS PERSON # VEHICLE # AME DATE OF BIRTH INJ I SEX I LOC'. S F-17 CT HU EP ABID 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 NM Tr part 2 EMS S law EnMcemaM Tr OtNa1, En— In Na— W Unbwwn ❑ PERSON* VEHICLE # AME DATE OF BIRTH INJ SEX LOC: S R O EJECT HU EP ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not TrarnponaC 2 EMS S law EMmcemeM ]T d . E.1aln h Nartatrve BE UMaawn ❑ ADDITIONAL VIOLATIONS 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 DEPARTMENT TYPE OF DEPT. 748 SGT PASSEGGIATA GULF STREAM POLICE DEPARTM POLICE DEPARTMENT (PD) HSMV 90010 S 4 5 Page of_ REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER DIAGRAM 19-2175 1 87073119 Little Club Rd Vehicle No.1 Final Rest Stop /11 Town Of Gulf Stream Monument Second Impact U Q FPL ELECTRIC POLE First Impact �O HSMV 90010 S 5 Page _ 5 of N Z 1 t H NOT TO SCALE