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HomeMy Public PortalAboutPRR 22-2879o: +15614481009 Page: 1 of 2 2022-04-11 18:36:08 GMT From: Jonathan Birkman Marsiad Qur4ish i,L'sq, 01. �15-4-261 .7968 iiiai-sad@qbia�vgr,oi.jp.;,cor.,ri To: A: i i DE PARVAGN 100. 'S)� ,,A IROAD f-7 V QT 1:0 L: A k A 4I-43AS HANN WY PIIAI 04/0 -3/2 0 2 2 2) 00701 Oulk Cu.1'NT'-- DA'rtl' AcCIDEN. V: G IJ "'I "STREANXI A.pRIL I L 2CQ2 --I 14_8 -1 Q99), Tn. 561 3 8 9.113 9.; o n a.t I p n eq b avv Pro k t 1) 0, rn . PEREZ ject.ion with the abow, it, eot)i Please be advised that our I-ClIt"eSelItS SFBAS."Ij,�.N.♦ WYS referenced NIVA ms- . W6 occurred.. oij AI'Ri(. 31, 2022.2— E11010sed please find an :executed mORNI. FOR 'I "RAFFIC CAM.11 RFAI.ORI. Ple"I C a copy Qftho aoident report NN-Iten :I.t is available, I'liank You., MARS.,'U) Q1."IRAISHI, FAQ. End,: Asslated, 809 SE 8d, St; Deerfield Bch. FL 3'v4-t-1.�ie.'tepEior).t,561.444,8370 fax.561.431.0385 o:+15614481009 Page: 2 of 2 2022-04-11 18:36:08 GMT From: Jonathan Birkman Sworn Statement to Obtain Traffic Crash Report Information Pursuant to Section 3 16. 1 066(2), Florida Statutes, motor vehicle crash information is.confidential and exempt f rorri disclosure for a period of 60days after the. crash report is4iled. 'Obtaining confidential information when not entitled to do sols a felony violation. GPD Case No,. .20701 The undersigned requests the following crash. report (data/location/parties involved): .. Date, 04/0312022 Location: Al. A (North of Woolbright) Our r-lient: Sebastian Wys Perez The undersigned statesthathe/she. or the organization represented qualify for immediate disclosure of the crash report .accqrdin tothe e Xemptlon checked below and do es swear or affirm that the information contained in a"crash report rriade:co.nfidential by statute will nat iae used for: any commercial solicitation of crash victims, orknowingly be disclosed toany third party,fo r tli�y.purpove of such solicitation during the period.oftime that the infarrnabon remains, confidential. D I am a party involved in the.crash, I am a legal representative ton party involved in the crash. Florida Bar Number.,0023790 D J arts alicensedins,orprice agent to. a. party involved:irl the crash, their insurer or insurers to which they applied for insurance coverage, Florida Liceose N.Umber., 171 Lain a person Under contract to provide claims or underWriting information to a qualifying insurance company, identified as-, I:a.rn.a:.,pTq5ert4tin.gao.thori:ty...Flor:ida:Blar Nurriber,;, EJ I represent z, radio or televisi6n station licensed by the FCC o, r n ewspa pe r qualified to publish legal notices or a free newspaper of general circulation,.as def lined in Section 316,066(2).(b), Florida ...Statutes. Nanig o.f.:i-adi.u/te.levision/n.ew5papHr: D Ire present a local,. state or fed era la &ejricy that is authorized by law to have access to crash reports. Name of local/state/federal agency: represent a Victim Service s Program, as defined, in Section 316,003( 1 8), Florida Statutes, ., Name of Program.-. Marsad Qijrais,hj,, Esq. Telephone Nurn bLr with Area Code State. of Florida County of Broward Quraishi & Kirkman, PL Age ncy/Business/Repres-ented 809 SESth Street Address Daerfie.ld Beach,:K .33441 QtYj State Zip Code Swornflor affirWe,d). and subscribed before me by means of Mph . ysical presence or Cl online notarization this 11 Nkttk fit April 20.�2. IjyMarsad Ourai hi,Esq, Per uced Identification (ID) 0 Type ID aced Pr Notary Name: Sign Lire 0 ary Public or A Certified % LaW t or Correctional Officer F6 )?Vise-d.March$bz0] L nfcirc�een IN Sk TATE, ..,,NX' TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered via e-mail April 12, 2022 Marsad Quraishi [mail to: jonathan@qblawgroup.com] Re: GS #2879 (Crash Report) Would like a copy of the police crash report #22-0701. Dear Marsad Quraishi [mail to: jonathan@qblawgroup.com]: The Town of Gulf Stream has received your public records request dated April 11, 2022. I have attached the report to the e-mail for your convenience, as Motor Vehicle Crash Reports are confidential for a period of 60 days after the report is filed and they are not available to the general public during this time. On June 12, 2022, after expiration of the 60-day period, per Florida Statute § 316.066(2)(a), you should also be able to view your original request and response at the following link : https://portal.laserfiche.com/Portal/DocView.aspx?id=178695&repo=r-430100cc We consider this request closed. Sincerely, Reneé Rowan Basel As requested by Rita Taylor Town Clerk, Custodian of the Records VEHICLE # 1 Check if Commercial Reporting Agency Case Number HSMV Crash Report Number ❑ 1 220701 87073137 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN 2 Parked Motor VehiGe 3 Working Vehicle28APEW 1 FL 09116/2022 Registration ❑ 1 FTMF1C52MKE33973 Hit and Run 1 No 1 YEAR MAKE MODEL STYLE COLOR DAMAGE: 1 Disabling 4 Minor EST. AMOUNT 2 Yes 88 Unknown 2021 FORD F150 PICKUP BLUE - BLU 2 Functional 1 3 None 88 Unknown 1$30,000.00 INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due to Damage: 2 VEHICLE REMOVED BY 1. Rotation 2. OwnDrier Request 1 ALLSTATE 981868473 1 No 2 Yes ZUCCALAS TOWING 3. 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ CURRENT ADDRESS CITY & STATE ZIP TODD MCMILLIN HART "19 DANSON WAY DELRAY BEACH FL 334115 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES One: Registration r, 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 ❑ ❑ El El El SIR A1A 35 35 2 HAZ. MAT. RELEASED 1 No HAZ. MAT. PLACARD 1 No NUMBER CLASS Area of Initial Impact Most Damaged Area 14 01 2 Yes 2 Yes ❑ 2 3 4 5 6 7 18 Undercarriage 18 2 3 4 5 6 7 88 Unknown BS Unknown 1 15 16 17 8 19 Overturn 19 1 15 16 17 8 20 Windshield 20 MOTOR CARRIER NAME US DOT NUMBER 14 9 21 Trailer 21 14 9 13 121110 13 121110 MOTOR CARRIER ADDRESS CITY STATE I ZIP CODE PHONE NUMBER Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 16 (Sport) Utility VehiGe 1 1 Vehicle 10,000 Ibs or less Placarded 8 Traclor/rdple 1 Two -Way, Not Divided 3 17 Cargo Van (10,000 Ibs for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 2 Two -Way, Not Divided, with a (4,53kg) or less) Continuous Left Lane ❑ 2 Single -Unit Truck (2-axle and GVWR kg), Cannot Classify 1 Passenger Car 18 Motor Coach ,4,k 3 Two -Way, Divideed,d, more than 10000Ibs536 Unprotected ( g)) 10 Bus/Large van (seats for 9-15 2 Passenger Van 19 Other Light Trucks (10,000 Ibs (painted >4 feet) Median 3 Single -Unit Truck (3 or more axles) occupants, including driver) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 4 Truck Pulling Trailers) 11 Bus (seats for more than 15 7 Motor Home 20 Medium/Heavy Trucks (more Median Barrier 5 Truck Tractor (bobtail) occupants, including driver) 8 Bus than 10,000 lbs (4,536 kg)) 5 One -Way Trafficwa 6 Truck Tractor/Semi-Trailer 77 Other, Explain in Narrative y 7 Truck Tractor/Double Truck 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 88 Unknown 12 Moped 77 Other, Explain in Narrative Trailer Type 13 All Terrain Vehicle (ATV) 88 Unknown 1 Single Semi Trailer 8 Pole Trailer Semi Cargo Body Type Comm/Non-Commercial TRAILER 1 TRAILER 2 2 Tandem Trailer 9 Towed Vehicle 13 Intermodal 3 Tank Trailer 10 Auto Transport 1 Interstate Carrier1:11:1 3 Van/Enclosed Box Container Chassis 4 Saddle Mount trailer 77 Other, Explain in Chassis 5 Boat Trailer Narrative 1:14 Hopper 14 Vehicle Towing 2 Intrastate Carrier ❑ 5Pote-Trailer Another Vehicle6 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 Ibs Most Harmful Event Non -Collision 1 10,000 Ibs (4,536 kg) or less 8 Dump kg) or less not Comm 1 Overtum/Rollover GVWR/GCWR 4 2 10,001-26,000 Ibdisplaying (4,536-11,793kg) 9 Concrete Mixer displaying HIMplacard ❑ 2 Fire/Explosion 3 More than 26,000 Ibs (11,793kg) 10 Auto Transport 77 Other, Explain in 3 Immersion 4 Not Applicable 11 Garbage/Refuse Narrative 14 4 Jackkni/e 5 Cargo/Equipment Loss or Shift Collision with Non -Fixed Object Colllalon Fixed Ob)ect 12 Log 88 Unknown 10 Pedestrian 29 Cable Barrier Emergency 19 Impact Attenuator/Crash Cushion 6 FeIL/Jumped From Motor Vehicle 11 Pedalcycle 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) 9 Other Non -Collision 14 Motor Vehicle in Transport 22 Bridge Rail 33 Utility Pole/Light Support 1 Culverte ❑ 1st 2nd I40-46 Sequence of Events only] 15 Parked Motor Vehicle 34 Traffic Sign Support 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 1 No 45 14 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 42 Ran Off Roadway, Right Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox Vehicle 28 Guardrail End 39 Other Fixed Object (wall, 32 ❑ 43 Ran Off Roadway, Left 18 Other Non -Fixed Object building, tunnel, etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects Roadway Grade 45 Cross Centerline 46 Downhill Runaway 3 Turning Left 14 Slowing 1 Straight Ahead 13 Stopped in Traffic This Vehicle ❑ ❑ 1 Level 4 Backing 15 Negotiating a Curve 1 8 Flashing Signal 1 None 2 Hillcrest 16 Roadway Alignment ❑ 1 3 Uphill 5 Turning Right 16 Leaving Traffic Lane 9 Railway Crossing 1 No Controls 2 Brakes 13 Wheels 6 Changing Lanes 17 Entering Traffic Lane Device 4 School Zone Sign/ 3 Tires 14 Windows/ 4 Downhill 1 Straight 8 Parked 77 Other, Explain in Narrative 10 Person (including 2 Device 4 Lights (head, Windshield 5 Sag (bottom) 2 Curve Ri Right 10 Making U-Tum 88 Unknown Flagman, Officer, 5 Traffic Control signal, tail) 15 Mirrors 3 Curve Left 11 Overtaking/Passing assin Guard, etc.) Signal 6 Steering 16 Truck Coupling Special Function 77 Other, Explain in , 1 No Special Function 9 Ambulance 14 Intercity Bus 6 Stop SiNarrative gn 7 Wipers Trailer Hitch/ 1 of Motor Vehicle 2 Farts Vehicle 10 Fire Truck 15 Charter/tour Bus 7 Yield Sign 9 Exhaust System Safety Chains 88 Unknown 3 Police 11 Farts Labor Transport 16 Shuttle Bus 10 Body, Doors 77 Other, Explain in 7 Taxi 12 School Bus 17 Farm Labor Bus 11 Power Train Narrative 8 Military 13 Transit/Commuter Bus 88 Unknown 12 Suspension 88 Unknown ❑A Lei WGU L-JCNi PERSON* NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER 1 TODD MCMILUN HART 318.089 AILED TO USE DESIGNATED LANE/ FAILED TO DRIVE Al PKOHP VITHIN SINGLE PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER 1 TODD MCMILUN HART 322.15(1) DL NOT CARRIED/EXHIBIT ON DEMAND Al PKOIP PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV 90010 S 2 7 Page of _ WAS DOT PROPERTY INVOLVED IN THIS CRASH? FLORIDA TRAFFIC CRASH REPORT LONG FORM Fv] SHORT FORM ❑ UPDATE ❑ TOTAL # OF VEHICLE SECTION(S) 2 (Shaded Areas) 3 MAIL TO: DEPARTMENT OF HIGHWAY SAFETY & MOTOR VEHICLES TOTAL # OF PERSON SECTION(S) TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING TOTAL # OF NARRATIVE SECTION(S) 1 TALLAHASSEE, FL 32399-0537 CRASH DATE TIME OF CRASH DATE OF REPORT _____][REPORTIN AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 04/03/2022 7:51 PM 04103/2022 220701 187073137 CRASH IDENTIFIERS COUNTY CODE CITY CODE COUNTY OF CRASH PLACE OR CITY OF CRASH CHECK IF WITHIN IME REPORTED TIME DISPATCHED 08 1 PALM BEACH GULF STREAM CITY LIMITS [7:51 PM 7:51 PM TIME ON SCENE ]ME CLEARED SCENE CHECK IF REASON (If Investigation NOT Complete) Notified By: 1 Motorist 7:59 PM 19:12 PM COMPLETED 2 Law Enforcement ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAY AT STREET ADDRESS # © AT LATITUDE AND LONGITUDE S.R. A1A N OCEAN BLVD 26.493924 -80.054114 AT FEET MILES 1 N [11 S E W ATIFROM INTERSECTION WITH STREET, ROAD,HIGHWAY © OR FROM MILEPOST# 596 .� -1 LAKEVIEW DR Road System Identifier 7 Forest Road Type of Shoulder Type of Intersection 5 Traffic Circle 8 Private Roadway 1 Not at Intersection 6 Roundabout 1 Interstate 4 County ❑ 2 U.S. 5 Local 3 9 Parking Lot 1 Paved 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 3 Curb 4 Y-Intersection Narrative CRASH INFORMATION (CHECK IF PICTURES TAKEN) 1,41 Light Condition Weather Condition Roadway Surface Condition School Bus Related Manner of Collision/impact ❑ 1 Daylight 5 2 Dusk 5 Dark Not Lighted 6 DarkUnknown5 4 Flog, Smog, Smoke 5 SleetMaiU 1 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 Blowing Sand, Soil 1 8 Water 1 Directly Involved 6 Rear to Side 4 Dark -Lighted 77 Other, Explain in Dirt 1 Clear (standing/moving) 3 Yes, School Bus 7 Rear to Rear 1 Front to Rear Narrative 88 Unknown 7 Severe Crosswinds 2 Cloudy 77 Other, Explain in 1 Dry 77 Other, Explain in 2 Wet Narrative Indirectly Involved 77 Other, Explain in Narrative 2 Front to Front 3 Rain 3 Angle 88 Unknown Narrative 4 Ice/Frost 88 Unknown First Harmful Event Non -Collision Collision Non -Fixed Object Collision with Fixed Object First Harmful Event 1 Overturn/Rollover 10 Pedestrian 19 ImpactAttenuator/Crash 30 Concrete Location 2 Fire/Explosion 11 Pedalcycle Cusion 31 Other Traffic Barrier 1 On Roadway 3 Immersion 12 Railway vehicle (train, 20 Bridge Overhead Structure 32 Tree (standing) 2 Off Roadway 14 4 Jackknife engine) 21 Bridge Pier or Support 33 Utility Pole/Light Support 3 Shoulder 5 Cargo/Equipment 13 Animal 22 Bridge Rail 34 Traffic Sign Support 4 Median First Harmful Event Loss or Shift 14 Motor Vehicle in 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 B 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 Ob'ect First Harmful Event Relation to Contributing Circumstances: Road 9 Worn, Travel -Polished Surface Contributing Circumstances: Environment 1 ❑ Junction 5 Railway Grade Crossing 1 4 En tion Exit Ramp ❑ ❑ ❑ 10 Rod Surface Condition (wet, 1 icy, snow, slush, etc.) 11 Obstruction in Roadway ❑ El ❑ 1 Non -Junction 15 Crossover - Related 16 Shared -Use of Path or Trail 12 Debris 1 None 13 Traffic Control Device 1 None 5 Animal(s) in Roadway y 2 Intersection 17 AcceleratioNDceleration Lane 4 Work Zone (construction/ Inoperative, Missing or Obscured P 9 2 Weather Conditions 77 Other, Explain in 3 Intersection -Related 18 Through Roadway 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 Zone 1 No 2 Yes Fil warning Sign 2Advance Waming Area 3 Transition Area ❑ 2 Lane Shift/Crossover 3 Work on Shoulder or Median 4 Intennittent or Moving Work ❑ 1 No 2 Yes 1 No 2 Officer Present 88 Unknown 4 Activity Area Other, Explain in Narrative 88 Unknown 3 Law Enforcement Vehicle 5 Termination Area 77 Only Present TNESSES NAME ETHAN TERRY ADDRESS 614 S. WAYNE STREET CITY & STATE LEWISTOWN ZIP CODE PA 17044 NAME ADDRESS CITY & STATE ZIP CODE NAME ADDRESS CITY & STATE ZIP CODE N N VEHICLE PROPERTY DAMAGE VEH. # PER # [ROPERTY DAMAGE -OTHER THAN VEH. EST. AMT OWNER'S NAME (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE VEH. # PER # [ROPERTY DAMAGE -OTHER THAN VEH. EST. AMT. OWNER'S NAME (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE HSMV 90010 S 1 7 Page of — Reporting Agency Case Number HSMV Crash Report Number PERSON # 1 220701 87073137 1 Driver VEHICLE # NAME PHONE NUMBER Check if ❑ 2 Non -Motorist 1 3 Passenger ❑ 1 TODD MCMIWN HART Recommend Driver Re -exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 4619 DANSON WAY DELRAY BEACH FL 33445 DATE OF BIRTH SEX. 1 Male ❑ DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4 Incapacitating 1 None 5 Fatal (within 30 days) 3 02/17/1969 2 Female 88 Unknown H630813690570 FL 02/17/2028 2 Possible 3 Non -Incapacitating 6 Non -Traffic Fatality DL Type Required Endorsements 1st Drivers Actions at Time of Crash 3rd Condition At ❑ 1 A 2 8 3 C 1 No Contribution Action 26 Ran off Roadway Time of 7 ❑5 4 D/Chauffeur 3 1 Yes 25 2 Operated MV in Carelss or 27 Disregarded other Traffic ❑ Crash ❑ ❑ Negligent Manner 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 Turn29 Over-Correcting/Over 6 Seizure, Epilespsy, Blackout Driver Distracted By 4 Other Inside the Vehicle Steering 7 Physically Impaired (explain in narrative) 10 Followed too Closely 1 Not Distracted 2nd 8 Emotional (depression, 88 5 External Distraction 11 Ran Red Light 30 Swerved or Avoided :Due 4th angry, disturbed, etc.) 2 Electronic Communication 12 Drove too Fast for Conditions to Wind, Slippery Surface, MV, Devices (cell phone, etc. in narrative) 13 Ran Stop Sign Object, Non -Motorist in ❑ 9 Under the Influence of (outside the vehicle, explain El Medications/Drugs/Alcohol 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 Erratic, 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 1 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) 3 Restraint Systems (RS) DRIVER OR PASSENGER E 1 DOTCompliant ❑ 1 Yes Motorcycle Helmet 2 No SEAT ROW OTHER Motor Vehicle Seating Position: LOCATION: 2 Other Helmet 3 Not Applicable 1 Not Applicable (non -motorist) (LOC) 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 9 3 Other Enclosed Cargo Area Ejection (EJECT) 6 Restraint Used - Type Unknown 77 Other 3 Third 4 Unenclosed Cargo Area 1 Not Ejected 1 NotApplicable 6 Deployed- 7 Child Restraint System - Forward Facing 3 (explain in 4 Fourth 2 Ejected, Totally 2 Not Deployed Combination 8 Child Restraint System -Rear Facing 5 Trailing Unit 1 Booster Seat narrative) 77 Other ROW 3 Ejected, 3 Deployed -Front 7 Deployed -Curtain 9 to ment 10 Child Restraint Type Unknown 88 Unknown 6 Riding on Motor Vehicle Exterior (non- Partially 4 Deployed -Side 88 Deployment 88 Unknown trailing unit) 4 Not Applicable 77 Other, Explain in Narrative Unknown 88 Unknown 88 Unknown ❑ e CntM torlat Description 1 Pedestnan Non -Motorist Location At Time of Crash 8 Sidewalk ❑Action Prior to Crash 1 Intersection - Marked Crosswalk 5 Walking/Cycling on Sidewalk 9 Median/Grossing Island 2 Other Pedestrian (wheelchan, person in a 6 In Roadway Other (working. 2 Intersection -Unmarked Crosswalk 10 Driveway Access y — Driveway Access 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 ck - Marked Crosswalk 7 Adjacent to y (e.g., 12 Non-Trafficway Area 2 Waiting to Cross Roadway 4 Other Cyclist 5 Occupant of Motor Vehicle Not in Transport fan)Rao 5 Travel lane -Other Location shoulder, median) Travel 77 Other, Explain in Narrative 3 Walking/Cycling Along 6 Bicycle Lane 8 Going to from School (K-12) (parked, etc.) 88 Unknown Roadway with Traffic (in or in 7 shoulder/Roadside 9 Working in Trafficway adjacent to travel lane) 6 Occupant of a Non -Motor Vehicle (incident response) 4 Walking/Cycling Along Transportation DeviceNon-Motoriston 7 Unknown Type of Non -Motorist rcums antes 10 None 1No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative tar ❑ 2 Dart/Dash or adjacent to travel lane) 88 Unknown 3 Failure to Yield Right -of -Way 4 Failure to Obey Traffic Signs 7 Entering/Exiting Parked/Standing 10Improper Tum/Marge 1 None Safety Equipment 5 Lighting 2 Helmet 6 Not Applicable 3 Protective Pads Used ❑ Signals, or Officer ❑ z� 5 In Roadway Improperly (standing, Vehicle 11 Improper Passing 77 Other, Explain (elbows, knees, shins, etc.) lying, working, playing) 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking in Narrative 4 Reflective Clothing (jacket, 88 Unknown 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative ❑ backpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown ALCOHOL/DRUG/EMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: [ALCOHOL BAC USPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT: ALCOHOL 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 ❑ Test Not Given Test Refused 1 Blood 3 Urine 1 Positive 2 Negative ❑ 2 Yes 3 Test Given Other, Explain 1 77 e 3 Pending 88 Unknown 88 Unknown, 'rfTested in Narrative in 88 U12 NKNOWN KNOWN 8 Unknown 88 Unknown, if Tested Explainven n 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 DELRAY BEACH FIRE RESCUE D622004607 DELRAY BEACH MEDICAL CENTER 77 Other, Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON # [=AME DATE OF BIRTH I INJ I SEX I LOC: S I R 0 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 NO T.nVO E 2 EMS 3 L Enlaco i 77 c— EVWin In Nl rw W Un� ❑ PERSON 11 VEHICLE # [AME DATE OF BIRTH INJ I SEX I LOC: S I R O 1 EJECT I HU EP ABD IRS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nd Tninpu 2 EMS 3l Enfucertwn177 at Eml m in N_W W Unk�wxn ❑ HSMV 90010 S 3 7 Page of — Reporting Agency Case Number HSMV Crash Report Number NARRATIVE 220701 1 87073137 Veh-1 traveling northbound in the 3000 block of SR(A1A). Veh-2 traveling southbound in the 3000 block of SR(A1A) Veh-1 fails to maintain a single lane and veers into the southbound lane on SR (Al A). Veh-1's drivers side front collides with veh-2's drivers side rear. Veh-1 side swipes Veh-2 and then collides with a tree on the southbound lane of SR (Al A). Veh-2 rear axel was dislodge from the vehicle causing it to be disabled in the southbound lane on SR (Al A) Driver of veh-1 was taken to Delray Medical center for minor injuries. Both vehicles were towed from the scene by Zucccala's Towing. ADDITIONAL PASSENGERS PERSON ]VEHICLE # AME DATE OFBIRTH INJ I SEX I LOC: S I R O 1 EJECT HU EP ABD IRS 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 Transpo . 2 EMS S law Enforcement 77 gfbr, EmWi in Na w 88 UnWgwn ❑ PERSON # VEHICLE # AME DATE OF BIRTH INJ SEX ILOC:S IR O 1 EJECT HU EP I AB D IRS 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 1 NO Tr pa 2 EMS 3 — Enlacement T/ Wier. E, 4Wn in Nartnrve 88 Unbuvn ❑ JEMS 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. 762 OFFICER ROBERT COPPIN GULF STREAM POLICE DEPARTM POLICE DEPARTMENT (PD) HSMV 90010 S 4 7 Page of REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER DIAGRAM 220701 1 87073137 NOT TO SCALE point of impact SR (A1A) ki HSMV 90010 S 5 7 Page of — VEHICLE # 2 Check if Commercial Reporting Agency Case Number HSMV Crash Report Number ❑ 220701 87073137 1 VehiGe in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES 103/11/2023 Check if Permanent VIN 2 Parked Motor VehiGe 3 Working Vehicle 1 62ATBW FL Registration ❑ 1CSRD7MT2CS114932 Hit and Run 1 No YEAR MAKE MODEL STYLE COLOR DAMAGE: 1 Disabling 4 Minor EST. AMOUNT 2 Yes 1 12012 DODO RAM 1500 TK BLACK - BILK 2 Functional 1 88 Unknown $40,000.00 88 Unknown 3 None INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due to Damage: 2 VEHICLE REMOVED BY 1. Rotation 2. Owner Request 1 PROGRESSIVE SELECT INSU 852590790 1 No 2 Yes ZUCCALAS TOWING 3. Driver 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ CURRENT ADDRESS CITY & STATE ZIP SEBASTIAN WYS PEREZ 3640 SHERWOOD BLVD DEL.RAY BEACH FL 33445 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 ❑ RiEl L.1 1:1 ❑ ❑ SR A1A 35 35 2 HAZ. MAT. RELEASED 1 No HAZ. MAT. PLACARD 1 No NUMBER CLASS Area of Initial Impact Most Damaged Area 11 10 2 Yes ❑ 2 Yes ❑ 2 3 4 5 6 7 18 Undercarriage 18 2 34546 88 Unknown 88 Unknown19 1 15 16 17 8 20 Windshield 20 1 15 MOTOR CARRIER NAME US DOT NUMBER 14 g 21 Trailer 21 14 13 1211 10 13 MOTOR CARRIER ADDRESS CITY TA STE ZIP CODE E NUMBER F Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 3 16 (Sport) Utility Vehicle 1 Vehicle 10,000 Ibs or less Placarded 8 Tracton Triple 1 1 Two -Way. Not Divided for Hazardous Materials 9 Truck more Man 10,000 lbs (4,536 17 Cargo Van (10,000Ibs 2 Two -Way, Not Divided, a Truck kg), Cannot Classify (4,536 kg) or less) e Continuous Left Turn Lane ❑ 2 Single -Unit (2-axle and GVWR more than 10,000 Ibs (4,536 kg)) 10 Bus/Large van (seats for 9-15 1 Passenger Car 18 Motor Coach 3 Two -Way, Divided, Unprotected 3 Single -trod Truck (3 or more axles) occupants, including driver) - 2 Passenger Van 19 Other Light Trucks (10,000 Ibs (painted >4 feet) Median 4 Truck Pulling Trailer(s) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 11 Bus (seats for more than 15 Truck Tractor (bobtail) 7 Motor Home ier 20 Medium/Heavy Trucks (more Median Barrier occupants, including driver) 6 Truck Tractor/Semi-Trailer 8 Bus than 10,000 Ibs (4,536 kg)) 5 One -Way Trafticway 77 Other, Explain in Narrative 7 Truck Tractor/Double Truck 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 88 Unknown 12 Moped 77 Other, Explain in Narrative Trailer Type 1 Single Semi Trailer 8 Pole Trailer 13 All Terain Vehicle (ATV) 88 Unknown Cargo Body Type Comm/Non-Commercial 2 Tandem Semi Trailer TRAILER 1 TRAILER 2 3 Tank Trailer 9 Towed Vehicle 13 10 Auto Transport 1 Interstate Cartier 3 Van/Enclosed Box Container Chassis ❑ 4 Saddle Mountfrrailer 77 Other, Explain in ❑ 4 Hopper 14 Vehicle Towing 5 Boat Trailer Narrative ❑ 2 Intrastate Carrier ❑ 6 Utility Trailer 5Pnle-Trailer Another Vehicle B8 Unknown 3 Not in Commerce/Government 7 House Trailer 6 Cargo Tank 15 Not Applicable 1 No Cargo 4 Not in Commerce/Other Truck 7 Flatbed (vehicle 10,000 Ibs Most Harmful Event Non -Collision 1 10,000 Ibs (4,536 Comm kg) or less 2 Bus 8 Dump (4,536 kg) or less not 1 Overturn/Rollover 2 10,001-26,000 Ibs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard GVWR/GCWR 2 Fire/Explosion 3 More than 26,000lbs It 1,793kg) 10 Auto Transport 77 Other, Explain in Immersion 4 Not Applicable 11 Garbage/Refuse Narrative3 14 4 Jackknife Cargo/Equipment Loss or Shift Collision with Non -Fixed Object 10 Pedestrian 12 Log 88 Unknown Collision Fixed Object5 29 Cable Barrier Emergency 19 Impact Attenuator/Crash Cushion 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 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) 9 Other Non -Collision 14 Motor Vehicle in Transport 22 Bridge Rail 1 23 Culvert 33 Utility Pole/Light Support ❑ 1st 2nd 15 Parked Motor Vehicle 34 Traffic Sign Support 14 ❑ [40.46 Sequence of Events only] 16 Work Zone/Maintenance 40 Failure tire, Equipment 24 Curb 35 Traffic Signal Support 25 Ditch 36 Other Post, Pole, or Support 1 No equipment (blown 2 Yes brake failure, etc.) 17 Struck By Falling, Shifting Cargo or 26 Embankment 37 Fence 88 Unknown 41 Separation of Units Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox 3rd 4th ❑ ❑ 42 Ran Off Roadway, Right 43 Ran Off Roadway, Left Vehicle 18 Other Non -Fixed Object 28 Guardrail End 39 Other Fixed Object (wall, building, tunnel etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects Roadway Grade 45 Cross Centerline 46 Downhill Runaway 1 Straight Ahead 13 Stopped in Traffic 3 Turning Left 14 Slowing This Vehicle ❑ ❑ 1 Level 4 Backing 15 Negotiating a Curve 1 8 Flashing Signal 1 None 2 Hillcrest Roadway Alignment 1 3 Uphill 1 5 Turning Right 16 Leaving Traffic Lane 6 Changing Lanes 17 Entering Traffic Lane 9 Rahway Crossing 1 No Controls 2 Brakes 13 Wheels Device 4 School Zone Sign/ 3 Tires 14 Windows/ Al Downhill 1 Straight 8 Parked 77 Other, Explain in Narrative 10 Person (including 3 Device 4 Lights Windshield 5 Sag (bottom) ght 2 Curve Right 10 Making U-Turn 88 Unknown ahead, Flagman, Officer, 5 Traffic Control signal, tail) 15 Mirrors 3 Curve Left 11 Overtaking/Passing Guard, etc.) Signal 6 Steering 16 Truck Coupling Special Function 1 No Special Function 9 Ambulance 14 Intercity Bus 77 Other, Explain in 6 Stop Sign 7 Wipers Trailer Hitch/ Narative of Motor Vehicle 2 Farm Vehicle 10 Fire Truck 15 Charter(rour Bus 7 Yield Sign 9 Exhaust System Safety Chains 88 Unknown 1 3 Police 11 Farm Labor Transport 16 Shuttle Bus 10 Body, Doors 77 Other, Explain in 7 Taxi 12 School Bus 17 Farm Labor Bus 11 Power Train Narrative 8 Military 13 TransittCommuter Bus 88 Unknown 1 1 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 6 7 Page of _ Reporting Agency Case Number HSMV Crash Report Number PERSON # 2 220701 87073137 1 Driver VEHICLE# NAME PHONE NUMBER heck if ❑ 2 Non -Motorist 1 ❑ 2 Recommend Re 3 Passenger SEBASTIAN WYS PEREZ Driver -exam CURRENT ADDRESS (Number and Street) CITY 8 STATE ZIP CODE 3640 SHERWOOD BLVD DELRAY BEACH FL 733445 DATE OF BIRTH SEX: 1 Male DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4lncapacrating one 5 Fatal (within 30 days) 2 03/11/2001 2 Female 88 Unknown W216780010910 FL JIN 03/11/2026 2 Possible 3 Non -Incapacitating 6 Non -Traffic Fatality DRIWIR DL Type Required Endorsements tat Drivers Actions at Time of Crash 3rd Condition At ❑ 1 A 2 B 3 C 1 No Contribution Action 26 Ran off Roadway Time of 1 9Disregarded other Traffic ❑ Crash r or 27 Fs] E Negligent Manner Sign 5 E/Operator 2 Nos 6 E/Oper-Rest 3 No Req. Endorsement 3 Failed to Yield Right -of -Way 28 Disregarded Other Road 1 Apparently Normal 3 Asleep or Fatigued 7 None 4 Improper Backing Markings 5 III (sick) or Fainted 6 Improper Turn 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 8 Emotional (depression, 1 Not Distracted 5 External Distraction 11 Ran Red Light 30 Swerved or Avoided: 1 2 Electronic Communication (outside the vehicle, explain 12 Drove too Fast for Conditions to Wind, Slippery Surface, MV, 4th angry, disturbed, etc ❑ 9 Under the Influencee of El13 Devices (cell phone, etc. in narrative) Ran Stop Sign Object, Non -Motorist in ❑ Medicetions/Drugs/Alcohol 3 Other Electronic Device 6 Texting 15 Improper Passing Roadway, etc. 77 Other, Explain in Narrative (navigation device, OVD player) 7 Inattentive 17 Exceeded Posted Speed 31 Operated MV in Erratic, 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 1 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) 3 Restraint Systems 1 DOT -Compliant ❑ 1 Yes IRS) DRIVER OR PASSENGER ::1 SEAT ROW OTHER Motorcycle Helmet 2 No Motor Vehicle Seating Position: LOCATION: 2 Other Helmet 3 Not Applicable 1 Not Applicable (non -motorist) (LOC) 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 2 Sleeper Section of Truck Cab 5 Deployed -Other 3 Right 2 Second Ejection (EJECT) 6 Restraint Used - Type Unknown Right 9 3 Other Enclosed Cargo Area 1 ( (knee, air belt, etc.) 77 Other 3 Third 4 Unenclosed Cargo Area 1 Not Ejected 1 Not Applicable 6 Deployed- 7 Child Restraint System -Forward Facing g 4 Rear Facing (explain in 4 Fourth ❑ 2 Ejected, Totally 2 Not Deployed 8 Child Restraint System - 1 Combination 5 Trailing Unit 3 Ejected, 3 Deployed -Front 9 Booster Seat narrative) 77 Other Row 7 Deployed -Curtain 6 Ridingon Motor Vehicle Exterior non- Partial) 10 Child Restraint Type Unknown 88 Unknown 88 Unknown y 4 Deployed -Side 86 Deployment yp trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown N n-Motorist Description 1 Pe�estnan Non -Motorist Location At Time of Crash 8 Sidewalk ❑ Action Prior to Crash 1 Intersection - Marked Crosswalk 5 Walking/Cycling on Sidewalk 9 MediaNCrossing Island 2 Other Pedestrian (wheelchan, person in a 6 In Roadway Other (working, 2 Inte section -Unmarked Crosswalk 10 Driveway Access y — building, skater, pedestrian conveyance, etc. 3 Intersection - Other4 Midblock - Marked Crosswalk11 Shared -Use Path or Trail 1 Crossing Roadway playing, etc.) 3 Bicyclist 4 Midblock -Marked Crosswalk 7 Adjacent to Raodway (e.g., 12 Non-Trafficway Area 2 Waiting to Cross Roadway 4 Other Cyclist 5 Travel Lane -Other Location shoulder, median) 77 Other, Explain in Narrative 3 Along 5 Occupant of Motor Vehicle Not in Transport 6 Bicycle Lane 88 Unknown Roadwa with Traffic in or 8 Going to or from School (K-12) Roadway with Traffic y ( (parked, etc.) 7 shoulder/Roadside 9 Working in Trafficway adjacent to travel lane) 6 Occupant of a Non -Motor Vehicle (incident response) 4 Walking/Cycling Along Transportation DeviceNon-Motoriston 7 Unknown Type of Non -Motorist rcuma ances 10 None 1No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative 1st El 2 Dart/Dash or adjacent to travel lane) 88 Unknown 3 Failure to Yield Right -of -Way ❑ 4 Failure to Obey Traffic Signs 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge 1 None Safety Equipment 5 Lighting 2 Helmet 6 Notlicable pp 3 Protective Pads Used Signals, or Officer snd 5 In Roadway Improperly (standing, Vehicle 11 Improper Passing 77 Other, Explain (elbows, knees, shins, etc.) 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking lying, working, playing) Narrative 4 Reflective Clothing Qacket, 88 Unknown 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative backpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown ALCOHOUDRUG/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 Test Refused ❑ 1 Blood 2 Breath 3 Urine EJ[2 EST RESULT ❑ ❑ DRUG USE: 1 1 No 2 E3 Test Not Given Test v ❑ 1 Blood 1 Positive ❑ 2 Yes L112 3 Test Given 77 Other, Explain88 COMPNETED Yes Test Genact 77 Other, 3 Pending Unknown 88 Unknown, if Tested in Narrative 8 UNKNOWN 8 Unknown 88 Unknown, if Tested Explain in Narrative 88 Unknown SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Transported 2 EMS 3 Law Enforcement 1 77 Other, Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON 11 VEHICLE # [AME DATE OF BIRTH INJ I SEX I LOC: S I R 1 0 EJECT J 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 Nat Trarupa I EMS 3 — Enl­ 77 Oilier. EWia in ❑ PERSON # VEHICLE # AME DATE OF BIRTH INJ I SEX I LOC: S I R 1 O 1 EJECT HU I EP I ABD IRS 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 ❑EMS 1 W Tnn�yorleE 2 EMS 3 Law EniorcemeM 77 Oltrm. E Win In Nartalrve eS Unbw`n HSMV 90010 S 7 7 Page of —