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HomeMy Public PortalAboutPRR 22-2881 T OWN OF G ULF S TREAM P ALM B EACH C OUNTY, F LORIDA Delivered via e-mail May 12, 2022 S. Fuentes \[mail to: sfuentes@bbbins.com\] Re: GS #2881 (Crash Report) Would like a copy of the police crash report #22-0874. Dear S. Fuentes \[mail to: sfuentes@bbbins.com\] The Town of Gulf Stream has received your public records request dated May 10, 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 July 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 FLORIDA TRAFFIC CRASH REPORT WAS DOT PROPERTY INVOLVED IN THIS CRASH? LONG FORM [] SHORT FORM J ] UPDATE r ] 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 04/28/2022 1 11:00 AM 04128/20 1 22-0874 187073139 CRASH IDENTIFIERS COUNTY CODE COUNTY OF CRASH PLACE OR CITY OF CRASH CHECK IF WITHIN IME REPORTED TIME DISPATCHED ICITYCODE CITY LIMITS 111:04AM O6 44 PALM BEACH GULF STREAM 11:04 AM TIME ON SCENE IME CLEARED SCENE CHECK IF REASON (If Investigation NOT Complete) Notified By: 1 Motorist 11:01 COMPLETED I J 2 11:08 AM PM 2 Law Enforcement ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAY AT STREET ADDRESS # © AT LATITUDE AND LONGITUDE BERMUDA LN 26.499379 -80.063923 AT FEET MILES N S E W AT/FROM INTERSECTION WITH STREET, ROAD,HIGHWAY © OR FROM MILEPOST # U 263 D �� SEA RD Road System Identifier 7 Forest Road Type of Shoulder Type of Intersection 5 Traffic Circle 1 Interstate 4 County ❑$ 2 U.S. 5 Local 8 Private Roadway 9 Parking Lot 1 Paved 2 Unpaved 1 1 Not at Intersection 2 Four -Way Intersection y 3 T-Intersection 6 Roundabout 7five-Point, or More 77 Other, Explain in Narrative 3 State 6 Tumpike/Toll Other, Explain in Narrative N 3 Curb 4 Y-Intersection CRASH INFORMATION (CHECK IF PICTURES TAKEN) -J, Light Condition Weather Condition Roadway Surface Condition School Bus Related Manner of Collision/Impact 1 Daylight 5 Dark -Not Lighted 1 2 Dusk 6 Dark -Unknown 4 Flog, Smog, Smoke 5 SIeettHail/ 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 4 Dark -Lighted 77 Other, Explain in 6 Blowing Sand, Soil 1 8 Water 1 Directly Involved 6 Rear to Side Narrative Dirt 1 Clear (standing/moving) 3 Yes, School Bus 1 Front to 7 Rear to Rear Rear 88 Unknown 7 Severe Crosswinds 2 Cloudy 1 Dry 77 Other, Explain in Indirectly Involved 77 Other, Explain in Narrative 2 Front to Front 77 Other, Explain in 3 Rain 2 Wet Narrative g8 Unknown Narrative 4 Ice/Frost 88 Unknown 3 Angle First Harmful Event Non -Collision Collision Non -Fixed Object Collision with Fixed Object First Harmful Event 1 Overtum/Rollover 10 Pedestrian 19 ImpactAttenuator/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 39 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 Obiect First Harmful Event Relation to Contributing Circumstances: Road g Worn, Travel -Polished Surface Contributing Circumstances: Environment Junction 1 5 Railway Grade Crossing 10 Road Surface Condition (wet, 77 1 icy, snow, slush, etc.) ❑ El11 ❑ ❑ ❑ 14 Entrance/Exit Ramp Obstruction in Roadway 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 2 Intersection 17 Acceleration/Dceleration Lane 4 Work Zone (construction/ Ino perative, Missing or Obscured 2 Weather Conditions 77 Other, Explain in 3 Intersection -Related 18 Through Roadway maintenance/ufility 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 1 2 Yes Warning Sign 2Advance Warning Area 3 Transition Area 2 Lane ShWCrossover 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 # 1 PROPERTY DAMAGE -OTHER THAN VEH. HOUSE EST. AMT 3000 OWNER'S NAME KAREN (CHECK IF BUSINESS) BURKE ADDRESS 3810 BERMUDA LN CITY & STATE GULFSTREAM ZIP CODE FL 33483 VEH. # PER # PROPERTY DAMAGE -OTHER THAN VEH. EST. AMT. OWNER'S NAME ❑ (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE HSMV 90010 S 1 6 Page of _ VEHICLE # 1 Check if Commercial �J Reporting Agency Case Number 1 HSMV Crash Report Number 22-0874 87073139 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN 2 Parked Motor Vehicle 3 Working Vehicle 1 NVRZ50 FL 06/30/2021 Registration ❑ 13C6TRVAG8KES14157 Hit and Run 1 No 1 YEAR MAKE MODEL STYLE VANINCLUDES COLOR DAMAGE. 1 Disabling 4 Minor 1 EST. AMOUNT 2 Yes 2019 RAM PROMASTER OPEN OR CLOSE WHITE - WHI Functional 88 Unknown $2,000.00 88 Unknown 3 INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due to Damage: 2 ❑ VEHICLE REMOVED BY 1. Rotation 2. Owner Request 2 GOVERNMENT EMPLOYEES IN 9100240221 1 No 2 Yes BECK'S TOWING 3. Driver 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS)/! CURRENT ADDRESS CITY & STATE ZIP GAMBIT ASO INC J 4800 N FEDERAL HWY BOCA RATON FL 3U31 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check ff Permanent VIN - YEAR MAKE LENGTH AXLES One: Registration [:-. Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check ff Permanent VIN YEAR MAKE LENGTH AXLES Two: Registration El VEHICLE N S E W Off -Road Unknown ON STREET, ROAD, HIGHWAY AT EST. SPEED POSTED SPEED TOTAL LANES TRAVELING ❑ ❑ D IV] ❑ 3810 BERMUDA LN 15 20 2 HAZ. MAT, RELEASED 1 No HAZ. MAT, PLACARD 1 No NUMBER CLASS Area of Initial Impact Most Damaged Area 14 14 2 Yes ❑ 2 Yes ❑ 3 4 5 6 3 4 5 6 2 7 18 Undercarriage 18 2 7 88 Unknown 88 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 12 1110 MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER Vehicle Body Type 15 Low Speed vehicle Tr afficway Commercial Motor Vehicle Configuration 16 (Sport) Utility Vehicle 17 1 Vehicle 10,000 Ibs or less Placarded 8 Tractor/Triple 1 1 Two -Way, Not Divided for Hazardous Materials 9 Truck more than 10,000lbs (4,536 17 Cargo Van (10,000 lb s 2 Two -Way, Not Divided, with a GVWR kg), Cannot Classify 4,536 k ( 9) or less) Continuous Left Turn Lane ❑ 2 Single -Unit Truck (2-axle and 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 -Unit 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 Trailers) 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 20 Medium/Heavy Trucks (more Median Barrier occupants, occupants, including driver) 8 Bus than 10,000 Ibs (4,536 kg)) 5 One-WayTrafficwa y 6 Truck Tractor/Semi-Trailer 77 Other, Explain in Narrative 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 7 Truck Tractor/Double Truck 86 Unknown 12 Moped 77 Other, Explain in Narrative Trailer Type 13 All Terrain Vehicle (ATV) 88 Unknown 1 Single Semi Trailer 8 Pole Trailer Cargo Body Type Comm/Non-Commercial 2 Tandem Semi Trailer TRAILER 1 TRAILER 2 Tank Trailer 9 Towed Vehicle modal 13 Inter 10 Auto Transport 1 Interstate Carrier ❑ ❑ 4 Saddle MounUTrailer 5 Boat Trailer Chassis 77 Other, Explain in ❑ 3 Van/Enclosed Box Container h 4 Hopper 14 Vehicle Towing Narrative 2 Intrastate Cartier 5Poie-Trailer Another Vehicle 6 Utility Trailer 88 Unknown7 3 Not in Commerce/Government 4 Not in Commerce/Other Truck House Trailer 1 No Cargo 6 Cargo Tank 15 Not Applicable 7 Flatbed (vehicle 10,000 Ibs Most Harmful Event Non -Collision 2 Bus 1 10,000 (4,536 kg) or less 8 Dump kg) or less not Comm 1 Overturn/Rollover GVWR/GCWR 4 2 10,001-2626,000 Ibdisplaying (4,536-11,793kg) 9 Concrete Mixer displaying HM placard ❑ 3 More than 26,000lbs (11,793kg) 10 Auto Transport 77 Other, Explain in 2 Fire/Explosion 4 Not Applicable 11 Garbage/Refuse Narrative 3 Immersion 12 Log 88 Unknown 4 Jackknife Collision with Non -Fixed Object 5 Cargo/Equipment Loss or Shift 10 Pedestrian 39 Collision Fixed Object 29 Cable Barrier Emergency 19 Impact /Crash Cushion 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 30 Concrete Traffic Barrier Vehicle Use 7 Thrown or Falling Object 12 Railway Vehicle (train, engine) OvAtterhead 20 Bridge Overhead Structure 31 Other Traffic Barrier Sequence Of Events 8 Ran into Water/Canal 13 Animal 21 Bridge Pier or Support 32 Tree (standing) 9 Other Non -Collision 14 Motor Vehicle in Transport 22 Bridge Rail 1 23 Culvert 33 Utility Pole/Light Support ❑ 1st 2nd 15 Parked Motor Vehicle [40-46 Sequence of Events only] 16 Work Zone/Maintenance 34 Traffic Sign Support 24 Curb 35 Traffic Signal Support 1 No 14 39 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 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 Crass Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Cross Centerline Roadway Grade 46 Downhill Runaway 1 Straight Ahead 13 Stopped in Traffic 3 Turning Left 14 Slowing This Vehicle ❑ 1 Level 4 Backing 15 Negotiating a Curve 1 8 Flashing Signal 2 Hillcrest Roadway Alignment 1 5 Turning Right 16 Leaving Traffic Lane 1 None 9 Railway Crossing 2 Brakes 13 Wheels 1 No Controls 1 3 Uphill ❑ 6 Changing Lanes 17 Entering Traffic Lane Device 4 School Zone Sign/ 3 Tires 14 Windows/ 4 Downhill 1 Straight 1 2 Curve Right 5 Sag (bottom) ght 8 Parked 77 Other, Explain in Narrative 10 Person (including Device 4. Lights (head, Windshield 10 Making U-Turn 88 Unknown Flagman, Officer, 3 Curve Left 11 Overtaking/Passing 5 Traffic Control Guard, etc.) sgnal, tail) 15 Mirrors 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/ Narrative 2 Farm Vehicle 10 Fire Truck 15 Charter/Tour Bus 7 Yield Sign 9 Exhaust System Safety Chains 1 of Motor Vehicle 3 Police 11 Farm Labor Transport 16 Shuttle 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 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 6 Page of PERSON # 1 Reporting Agency Case Number HSMV Crash Report Number 22-0874 87073139 1 Driver VEHICLE # NAME PHONE NUMBER Check2 L_ Non-Motonst 1 E Recommend 3 Passenger DANIELA AROCA AQUINO (661) 604-6084 Driver Re -exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 1401 S DEERFIELD AVE DEERFIELD BEACH FL 33441 DATE OF BIRTH SEX: 1 Male ❑ DRIVERS LICENSE NUMBER STATE EXPIRES t INJURY SEVERITY (INJ) 4 Incapacitating 1 None 5 Fatal (within 30 days) 12/09/1995 2 Female es Unknown A622160959490 FL 11/02/2022 2 Possible 3Nori-Incapacitating 6 Non -Traffic Fatality DRIVER DL Type Required Endorsements list Drivers Actions at Time of Crash 3rd Condition At ❑ wa Time f 1 Action 26 Ran off dother tManner 9D s ego dedribution Carelss or 27 Traffic ❑ Crash E 5 E/Operuattorr 2 No Negligent 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 Turn 29 Over-Correcting/Over Driver Distracted By 4 Other Inside the Vehicle Steering 6 Seizure, Epilespsy, Blackout (explain in narrative) 10 Followed too Closely 7 Physically Impaired 1 Not Distracted 2nd 8 Emotional (depression, 7 5 External Distraction 11 Ran Red Light 30 Swerved or Avoided : Due ( P 2 Electronic Communication (outside the vehicle, explain ❑ 12 Drove too Fast for Conditions 4th angry, disturbed, etc.) P to Wind, Slippery Surtace, MV, 77 Devices (cell phone, etc. in narrative 13 Ran StopSin 9 Under the Influence of 9 Object, Non -Motorist in 3 Other Electronic Device 6 Textin 15 Improper Passin Medications/Drugs/Alcohol gg Roadway, etc. device, DVD player) 77 Other, Explain in Narrative (navigation P Y ) 7 Inattentive 17 Exceeded Posted Speed 31 Operated MV in Erratic, P 68 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 2 Indement 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) Restraint Systems DRIVER OR PASSENGER 1 DOT -Compliant 1 Yes (RS) SEAT ROW OTHER Motorcycle Helmet 2 No 1:1 ❑ Motor Vehicle Seating Position: LOCATION: 2 Other Helmet 3 Not Applicable 1 Not Applicable (non -motorist) Seat Row Other (LOC) 1 1 3 No Helmet 2 None Used -Motor Vehicle Occupant 3 Shoulder and Lap Belt Used 1 Left 1 Not Applicable 4 Shoulder Belt Only Used 1 Front Air BagDeployed 2 Midde 2 Second 2 Sleeper Section of Truck Cab 5 Deployed -Other 5 Lap Belt Only Used 3 Right 3 Other Enclosed Cargo Area Ejection (EJECT) 6 Restraint Used -Type Unknown g (knee, air belt, etc.) 77 Other 3 Third 4 Unenclosed Cargo Area 1 Not Ejected 2 1 Not Applicable 6 Deployed- 7 Child Restraint System - Forward Facing (explain in 4 Fourth E2 Ejected, Totally 2 Not Deployed 8 Child Restraint System - Rear Facing 5 Trailing Unit Combination narrative 3 Ejected, 9 Booster Seat 77 Other Row 6 Ridingon Motor Vehicle Exterior non- 1 3 Deployed -Front 7Deployecl-Curtain 88 Unknown 88 Unknown ( Partially 4 Deployed -Side 88 Deployment 10 Child Restraint Type Unknown trailing unit) 4 Not Applicable 77 Other, Explain in Narrative Unknown 88 Unknown 88 Unknown ❑ N n-Motorist Description 1 Per�estnan ❑ Non -Motorist Location At Time of Crash 8 Sidewalk ❑ Action Prior to Crash 1 Intersection - Marked Crosswalk 5 Walking/Cyclingon Sidewalk 9 Median/Crossing 2 Other Pedestrian (wheelchari, person in a Island 2 Intersection Unmarked Crosswalk 6 In Roadway (working, building, skater, pedestrian conveyance, etc. - 10 Driveway Access —Other y 3 Intersection - Other4 Midblock -Marked Crosswalk 11 Shared Path Trail playing, etc.) 3 Bicyclist 4 Other Cyclist -Use or 1 Crossing Roadway 4 Midblock -Marked Crosswalk 12 Non-Trafficwa Area 7 Adjacent to Raodway (e.g., Y 2 Waiting to Cross Roadway 5 Occupant of Motor Vehicle Not in Transport 5 Travel Lane -Other Location 77 Other, Explain in Narrative g Y g g shoulder, median) P 3 Walkin /C clin Alon 6 Bicycle Lane 8 Going to from School (K-12) (parked, etc.) 6 Occupant of a Non -Motor Vehicle 88 Unknown Roadway with Traffic (in or in 7 shoulder/Roadside j ) (iWorking in ay adjacent to travel lane Transportation Device (incident response) oncTraffe) Non -Motorist Actions rcums antes 4 Walking/Cycling Along 10 None 7 Unknown Type of Non-Motonst F1st ❑ 1 No 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 3 Protective Pads Used 6 ❑ 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge z� ❑ Signals, or Officer Vehicle 11 Improper Passing In Roadway Improperly Other, 77 Other, Explain er, Explain (elbows, knees, shins, etc.) in Narrative (standing, 8 Inattentive (talking, g, ) Wrong -Way g g l lying, working, playing) ( g, eating, etc 12 Wron Wa Riding or Walking 4 Reflective Clothing (jacket, 88 Unknown 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative � backpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown ALCOHOUDRUG/EMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: LCOHOL BAC SUSPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT: ALCOHOL Test Not 2 Test Refused Given ❑ lood 2 Breath 7 BOther,, ❑ EST RESULT, ❑ []DRUG USE: ❑ I 2 Test Not Given ❑ Test 1 Blood 7Urine ❑ 1 Positive ❑ sUSE: 2 Yes 3 Test Given Explain 2 COMPLETED 3 ned Test Give Other, 3 Pendinc 88 Unknown 88 Unknown, if Tested in Narrative 88 UNKNOWN 88 Unknown 88 Unknown, ifTested 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 DELRAY BEACH FIRE RESCUE 77 Other, Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON* IVEHICLE#[AME DATE OF BIRTH I INJ I SEX I LOC: S I R 1 O EJECT J HU EP I ABD I RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 NM Tranap.r 2 EMS 3 Law Enlacement 77 a- E wn In N—bw W U­ ❑ JEMSAGENCY PERSON # VEHICLE # [AME DATE OF BIRTH I INJ SEX LOCH S R O 1 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 1WTranspWr 2 EMS 3 Law Enlomemml 77 Ol- EVlain In Narrative N Unkn ❑ HSMV 90010 S 3 6 Page of _ PERSON # 2 Reporting Agency Case Number HSMV Crash Report Number 22-0874 87073139 1 Driver VEHICLE # NAME PHONE NUMBER Check if rr 2 Non -Motorist � I I Recommend u 3 Passenger KAREN BURKE 5613300538 Driver Re -exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 3810 BERMUDA LN GULF STREAM FL T33483 DATE OF BIRTH SEX: 1 Male ❑ DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4 Incapacitating 1 None 5 Fatal (within 30 days) El 2 Female 88 Unknown 2 Possible 3 Non -Incapacitating 6 Non -Traffic Fatality DL Type Required Endorsements ❑ 1 A 2 B 3 C ❑ 4 D/Chauffeur 1 Yes 5 E/Operator 2 No 6 E/Oper-Rest 3 No Req. Endorsement 7 None Distracted By 4 Other Inside the Vehicle ❑Driver (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 Texting (navigation device, DVD player) 7 Inattentive 88 Unknown 1st Drivers Actions at Time of Crash ❑1 No Contribution Action 2 Operated MV in Caress or 26 Ran off Roadway 27 Disregarded other Traffic Negligent Manner Sign 3 Failed to Yield Right -of -Way 28 Disregarded Other Road 4 Improper Backing Markings 6 Improper Turn 29Over-Correcting/Over Steering 2nd 10 Followed too Closely 11 Ran Red Light 30 Swerved or Avoided: Due Drove too Fast for Conditions to Wind, Slippery Surface, MV, ❑12 13 Ran Stop Sign Object, Non -Motorist in 15 Improper Passing Roadway, etc. 17 Exceeded Posted Speed 31 Operated MV in Erratic, 21 Wrong Side of Wrong Way Reckless orAgreessive Manner 25 Failed to Keep in Proper Lane 77 Other Contributing Action ❑ 1 Vision Not Obscured 5 Load on Vehicle 9 Smoke 2 Inclement Weather 6 Building/Fixed Object 10 Glare 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 Motorcycle Helmet Motor Vehicle Seating Position: LOCATION: A 2 Other Helmet Seat Row Other (LOC) 3 No Helmet 1 Left 1 Not Applicable 3rd 4th DRIVER OR PASSENGER Condition At ❑ Time of Crash 1 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 Eye Protection (EP) ❑ Restraint Systems ❑ 1 Yes IRS) 2 No 3 Not Applicable 1 Not Applicable (non -motorist) 2 Middle2 1 Front Sleeper Section of Truck Cab Air Bag Deployed 5 Deployed -Other 3 Right 9 77 Other 2 Second 3 Third 3 Other Enclosed Cargo Area 4 Unenclosed Cargo Area Ejection (EJECT) 1 Not Ejected (knee, air belt, etc.) 1 NotA Ilcable pp 6 in 4 Fourth 5 Trailing Unit ❑ 3 Elected, Totally 2 Not Deployed Combination Combination narrative) 88 Unknown 77 Other Row 6 Riding on Motor Vehicle Exterior (non- 1 Partially 3 Deployed -Front 7Deployect-Curtain 88 Unknown trailing unit) 4 Not Applicable 4 Deployed -Side 88 Deployment 88 Unknown 88 Unknown Unknown 1 Pedestrian ' 2 Other Pedestrian (wheelchad, person in a 2 building, skater, pedestrian conveyance, etc. 3 Bicyclist 4 Other Cyclist 5 Occupant of Motor Vehicle Not in Transport (parked, etc.) 6 Occupant of a Non -Motor Vehicle Transportation Device 7 Unknown Type of Non -Motorist 2 None Used - Motor Vehicle Occupant 3 Shoulder and Lap Belt Used 4 Shoulder Belt Only Used 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 77 Other, Explain in Narrative Non -Motorist Location At Time of Crash 1 Intersection - Marked Crosswalk 8 Sidewalk 9 Median/Crossing Island Action Prior to Crash E 5Walking/Cycling on Sidewalk 12 2 Intersection - Unmarked Crosswalk 10 Driveway Access 6 In Roadway — Other (working, 3 Intersection - Other4 Midblock - Marked Crosswalk 11 Shared -Use Path or Trail 1 Crossing Roadway playing, etc.) 4 Midblock - Marked Crosswalk 12 Non-Trafficway Area 2 Waiting to Cross Roadway 7 Adjacent to Raodway (e.g., 5 Travel Lane - Other Location 77 Other, Explain in Narrative 3 Walking/Cycling Along shoulder, median) 6 Bicycle Lane 88 Unknown Roadway with Traffic (in or 8 Going( to or from School K-12) 7 shoulder/Roadside adjacent to travel lane) 9 Working in Trafficway on-1.1orist ActlonsIleircurns nces 4 Walking/Cycling Along (incident response) 10 None tsr 1 1 No Improper Action 2 Dart/Dash Roadway Against Traffic (in or adjacent to travel lane) 77 Other, Explain in Narrative 88 Unknown None Safety Equipment 5 Lighting Helmet 3 Failure to Yield Right -of -Way 4 Failure to Obey Traffic Signs Signals, or Or Officer 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge Protective Protective Pads Used 6 Not Applicable 77 Other, Explain ,,,rII�I 2', 15 In Roadway Improperly Vehicle 11 Improper Passing [bows, knees, shins, etc.) in Narrative I� lying, working, playing) 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking Reflective Clothing Qacket, 88 Unknown ❑ 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative 3ckpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown At Cnwni /rlRi irA/FMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: ALCOHOL BAC SUSPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT: AL COHOL USE: � Test Not 2 Test Refused Given ❑ 1 Blood 2 Breath 77 ❑ ❑ ❑ 1 DRUG USE: 2 E188 Test Not Test ❑ ood 17 Other, ❑3 1 Positive Yes 3 Test Given88 Ontth r, Explain 2 COMPLEGTED 3 Test Gv enedn Pendr2 Unknown 88 Unknown, rfTested in Narrative 88 UNKNOWN 88 Unknown Unknown, rfTested Explain in Narrative 88 Unknown SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Transported 2 EMS 3 Law Enforcement 1 77 Other. Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON ]VEHICLE # AME DATE OF BIRTH I INJ I SEX LOC: S R 1 O EJECT J HU 1EP 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 Nat Trancpo 2 EMS S law EnimcemeM 77-, Explain In Nartative W Unknavn ❑ PERSON ]VEHICLE # AME DATE OF BIRTH I INJ SEX LOC: S R 1 0 EJECT J HU EP 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 1 Nd T, liv— 2 EMS 3 Law Enforcement 77 Other. Explain in Nanafire 88ll.— ❑ JEMS HSMV 90010 S 4 6 Page of _ Reporting Agency Case Number HSMV Crash Report Number NARRATIVE 22-0874 87073139 VEHICLE 1 REVERSED INTO THE CIRCULAR DRIVEWAY OF 3810 BERMUDA LN. V1 STOPPED AT THE MIDDLE OF THE DRIVEWAY. DRIVER OF V1 MISTAKENLY PRESSED ACCELERATOR INSTEAD OF BRAKE. V1 THEN TRAVELED WEST INTO FRONT PORCH/ENTRYWAY OF 3810 BERMUDA LN. DAMAGE WAS CAUSED TO STEPS AND PORCH PILLAR. END. ADDITIONAL PASSENGERS PERSON # VEHICLE # AME DATE OF BIRTH INJ I SEX I LOC: S I R 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 EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nat Traaapo— 2 EMS 3 Law EnfwcemeM 11 Other. Explain In Narrative w unk ❑ PERSON # VEHICLE # AME DATE OF BIRTH INJ I SEX I LOC: S I R O I EJECT HU EP I ABD I 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 NM Transported 2 EMS 3 Law Enforcement ]] Oilier. Explain in ❑ JEMS Nam We. Unl 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. �750 IOFC POLICE DEPARTMENT TODD SUTTON GULF STREAM POLICE DEPARTM (PD) HSMV 90010 S 5 6 Page of_ DIAGRAM REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 22-0874 1 87073139 3810 BERMUDA LN HSMV 90010 S H -. 6 6 Page of IN]