TRAFFIC

C RASH REPORT *DENOTES MANDATORYYIfLD FOR SUPPLEMENT REPORT

LOCAL INFORMATION/<LAr6M,)

Ri9 -//O V

REPORTING AGENCY NAME*

/<‘f,/7-72

LOCAL REPORT NUMBER*

L/ I / / I

NCIC* HIT/SKIP NUMBER OF UNITS UNIT IN ERROR1-SOLVED L’

98-ANIMAL

L__J 2-UNSOLVED I I / I L_JZL] 99-UNKNOWN

OH-2 OH-3

E PHOTOSTAKEN

} OH-1P OTHERSECONDARY CRASH

E PRIVATE PROPERTY

ROADWAY

CDUNTY* LOCALITY* I LOCATION:CITY, VICLAGE,TOWNSHIP* CRASH DATE ITIME* CRASH SEVERITY

‘,1-CITY 1-FATAL2 -VILLAGE

II 3 -TOWNSHIP /%// I 2- SERIOUS INJURYROUTETYPE ROUTE NUMBER PREFIX 1 - NORTH LOCATION ROAD NAME ROAD TYPE LATITUDE DECIMAL DEGREES SUSPECTED

2 - SOUTH3- MINOR INJURY

.5 R .2 3-EASTL I I L____] 4-WEST [,/,4 TLE,.4’ i I 71 &LL.I /‘.._5 6171 71 SUSPECTED

ROUTETYPE ROUTE NUMBER PREFIX 1- NORTH REFERENCE ROAD NAME (ROAD, MILEPOST, HOUSE #) ROAD TYPE LONGITUDE DECIMAL DEGREES 4- INJURY POSSIBLE2 - SOUTH3- EAST

I I I I I L__J 4 -WEST Z-)// ,VZ. 2) I I LI.I 35 Y i & 2/

5- PROPERTY DAMAGEONLY

REFERENCE POINT DIRECTION ROUTE TYPE ROAD TYPE INTERSECTION RELATEDrAID REFERENCE

3- INTERSECTION 1- NORTH IR - INTERSTATE ROUTE(TP) AL - ALLEY HW- HIGHWAY RD - ROAD WITHIN INTERSECTION OR ON APPROACH/ 2- MILE POST 2- SOUTH US - FEDERAL US ROUTE AV - AVENUE LA - LANE SQ - SQUAREI____ 3-EASTLJ 3- HOUSE # BL - BOULEVARD MP - MILEPOST ST - STREET WITHIN INTERCHANGE AREA NUMBER OF APPROACHES4-WEST SR-STATE ROUTE

CR -CIRCLE OV -OVAL TE -TERRACEDISTANCE DISTANCE CR-NUMBERED COUNTY ROUTE

FROM REFERENCE UNtT OF MEASURE CT - COURT PK - PARKWAY TL - TRAIL1- MILES TR- NUMBEREDTOWNSHIP DR - DRIVE P1 - PIKE WA - WAY

r2-FEET ROUTE ROADWAY DIVIDED

t__j 3 -YARDS HE - HEIGHTS PL - PLACE

LOCATION OF FIRST HARMFUL EVENT MANNER OF CRASH COLLISION/IMPACT DIRECTION OF TRAVEL MEDIAN TYPE1- ON ROADWAY 9- CROSSOVER 1- NOT COLLISION 4- REAR-TO-REAR 1-NORTH 1-DIVIDED FLUSH MEDIAN

t]2-ONSHOULDER DO-DRIVEWAY/ALLEYACCESS

(

BETWEEN 5-BACKING (<4FEET)TWO MOTOR 2-SOUTH II

2-DIVIDED FLUSH MEDIAN3- IN MEDIAN 11-RAILWAY GRADE CROSSING L] VEHICLES IN 6 -ANGLE 3 EAST4- ON ROADSIDE 12-SHARED USE PATHS OR TRANSPORT 7- SIDESWIPE, SAME IIRECTIIN C 4 FEET)

4-WEST5-ON GORE TRAILS 2- REAR-END 8-SIDESWIPE, OPPOSITE DIRECTION 3- DIVIDED, DEPRESSED MEDIAN

6- OUTSIDE TRAFFIC WAY 13-BIKE LANE 3- HEAD-ON 9- OTHER / UNI<NOWN 4- DIVIDED, RAISED MEDIAN

7- ON RAMP 14-TOLL BOOTH (ANYTYPE)

8- OFF RAMP 99-OTHER / UNKNOWN 9- OTHER/UNKNOWN

WORK ZONE RELATED WORK ZONETYPE LOCATION OF CRASH IN WORK ZONE CONTOUR CONDITIONS SURFACE

1- LANE CLOSURE 1- BEFORETHE 1ST WORK ZONE

fl WORKERS PRESENT 2-LANE SHIFT/CROSSOVER WARNING SIGN

LAW ENFORCEMENTPRESENT3-WORIf ON SHOULDER 2-ADVANCE WARNINGAREA 1-STRAIGHTLEVEL 1-DRY 1-CONCRETE

OR MEDIAN 3 -TRANSITION AREA 2-STRAIGHTGRADE 2-WET 2-BLACKTOP,4- INTERMITTENT OR MOVING WORK 4- ACTIVITY AREA BITUMINOUS,

ACTIVE SCHOOL ZONE 5-OTHER 5-TERMINATION AREA3-CURVE LEVEL 3-SNOW ASPHALT

4-CURVEGRADE 4-ICE 3 - BRICKJBLOCIfLIGHT CONDITION WEATHER 9- OTHERJUNKNOWN 5- SAND, MUD, DIRT, 4- SLAG, GRAVEL,

1- DAYLIGHT 1- CLEAR 6- SNOW OIL, GRAVEL STONE

/ 2- DAWN/DUSK 2- CLOUDY 7- SEVERE CROSSWINDS 6- WATER (STANDING, 5- DIRT3-DARK- LIGHTED ROADWAY 3- FOG, SMOG, SMOKE B - BLOWING SAND, SOIL, DIRT, SNOW MOVING)

9- OTHERJUNKNOWN4- DARI( — ROADWAY NOT LIGHTED 4- RAIN 9- FREEZING RAIN OR FREEZING DRIZZLE 7- SLUSH

5- DARK — UNKNOWN ROADWAY LIGHTING 5- SLEET, HAIL 99- OTHER / UNI(NOWN 9- OTHER/UNKNOWN9-OTHER/UNKNOWN

I I

NARRATIVE (j•//‘ 2 3 c - - II Indicate the northdirection withan “N “ on the

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J_ I J - - LCRASH REPORTED DATE ITIME DISPATCH DATE/TIME

I7II8

POLICEAGENCY

IL(1OI /191 1/ rZ 7’ /)IS7I h2 t /r ?I IJIZI

ARRIVAL DATEITIME SCENE CLEARED DATE/TIME REPORTTAKEN BY

E MOTORISTTOTAL TIME I OTHER TOTAL I OFFICER’S NAME* I CH CC DRY OFFICER’S NAME*

ROADWAY CLOSED IINVESTIGATION TIME MINUTES /1/ 1. ,fy7 i 27L.£-::T i e

FT SUPPLEMENTL_.J ICORRECT(ON ,,ADUITION

OFFICER’S BADGE NUMBER* I CHECKED BY OFFICER’S BADGE NUMBER* I AR RAIIDIRG RIRDRD IAIISIl

I 0 I I / I I 2 I 7 I I II) I I I I I I

HSY7001 OH1 1/19 [760-0820] PAGE / OF

OHIO OEPORThENT

NIT

I I I I I I I I

LP STATE I LICENSE PLATE # I VEHICLE IDENTOFICATION N I VEHICLE YEAR I VEHICLE MAKE

I q/JjC/b7qgR I/)1IA)#I31FIA[/IMJWII i22/iPiii2j01 1i4l /—°,‘ct)INSIR6NEE INSURANCE COMPANY I INSURANCE POLICY N COLOR I VEHICLE MODEL

1VERWIEO CJAiVcg 5/7L/97STYPE OF USE I US OOT H I TOWEO BY: COMPANY NAME

cI IN EMERGENCY I IHAZAROOUS MATERIAL

INTERLOCK #OCCUPANTS VEHICLE WEIGHT GVWRIGCWRMATERIAL CLASS N PLACARO ID N

COMMERCIAL CGOYEBNMENT RESPONSE I I I I I I

1 - 1OK LOS. RELEASED

II 3 - >261< LOS. Q PLACARD

ri DEVICEEQUIPPEO C HIT/SKIP UNIT

o 2 / 2 - 10,001 - 26K LOS

1- PASSENGER CAR 7-MOTORCYCLE 2-WHEELED 02-GOLF CART OR-LIMO ILIVERYOEHICLEI

£2LLI2 - PASSENGER VAN IMINIVANI B - MOTORCYCLE 3-WHEELED 03- SNOWMOBILE 09- BUS 116+ PASSENGEOSI

3 - SPORT UTILITY VEHICLE 9- AUTOCYCLE 14 -SINGLE UNITTRACK 20-OTHER VEHICLEUNIT TYPE 4 - PICK UP 10- MOPED OR MOTORIZES 05-SEMI-TRACTOR 20 -HEAVY EQUIPMENT

5 - CURGO VAN DICYCLE 16-FARM EOUIPMENT 22-ANIMAL WITH RIEER o6-VAN 19-15 SEATS) 10 -ALLTERRAIN VEHICLE 17 -MOTORHOME ANIMAL-DRAWN VEHICLE

IATV 10001

LI2J # OFTRAILING UNITS

WAS VEHICLEOPERATING IN AUTONOMOUS 0- NOAATOMATION 3- CONDITIINALAATOMATIONMODE WHEN CRASH OCCURRED?

S-YES 2- NO 9-OTHER) UNKNOWN HUT

1 - DRIVER ASSISTANCE 4 - HIGH AUTOMATION

ONOMOUO 2 - PARTIALAUTOMATION S - FILLAATOMATIONMODE LEVEL

1- NONE 6- BUS —CHARTEBTOAR 11-FIRE 16-FARM 21- HAIL CARRIER

2- THAI 7-BUS — INTERCITY 12- MILITARY 17-MOWING 99-OTHER) UNKNOWN

3-ELECTRONIC RIDE SHARING B- BUS—SHUTTLE 13-POLICE SD-SNOW REMOVALSPECIALFUNCTION 4- SCHOOLTRANSPORT 9- BAS—OTHER 14-PUBLIC UTILITY 19-TOWING

5- BUS—TRANSIT/COMMUTER 10-AMBULANCE 15-CONSTRUCTION EQUIPHENT 20-SAFETY SERVICE PATROL

1 - NO CARGO BODYTYPE 3- VEHICLETOWING ANOTHER S - INTERHODAL CONTAINER B - POLE 12 -CONCRETE MIAER/NOTAPPLICABLE MOTOR VEHICLE CHASSIS 9- CARGOTANK 13-AUTITBANSPORTER

CARGO 2- BUS 4-LOGGING 6- CARGO VAN/ENCLOSED BOA DO-FLU? BEE 14-GARBAGLOEFASEBODYTYPE 7-GRAIN/CHIPS/GRAVEL 11-DUMP 99-OTHER/UNKNOWN

1-TARN SIGNALS 4-BRAKES 7-WORN DR SLICKTIRES 9- HOTORTROUBLE 99-OTHER/UNKNOWN

VEHICLE 2- HEAB LAMPS S - STEERING B - TRAILER EQUIPMENT 10 -IISAHLEO FROM PRIORDEFECTS 3-TAIL LAMPS 6-TIRE BLOWOUT DEFECTIVE ACCIDENT

1-INTERSECTION - MARKED 3-INTERSECTION—OTHER 6-BICYCLE LANE 9- MEDIAN/CROSSING ISLAND 02-FIRST RESPONDERLLJ CROSSWALK 4- MIOBLOCK— HARKED 7-SHOULDER) ROADSIDE 10-DRIVEWAY ACCESS AT INCIEENT SCENE

NIN-MBTDRIST 2- INTERSECTION - ANMARKEE CROSSWALK B - SIDEWALK 10-SHARED USE PATHS DR 99-OTHER? UNKNOWNLOCATION CROSSWALK S -THAAEL LANE—OTHER LOCATION THAILSAT IMPACT

O - NON-CONTACT 1 - STHAIGHTAHEAD 7-MAKING U-TURN 13-NEGOTIATING A CURVE OD-APPROACHING

LjJ

2- NON-COLLISION 2 - BACKING B - ENTERINSTRAFFIC LANE 14- ENTERING OR CROSSING OR LEAVING VEHICLE

3-STRIKING L_LL_/J 3-CHANGING LANES 9- LEAVINGTRAFFIC LANE SPECIFIED LOCATION 19-STANDING

ACTION 4-STRUCK PRE•CRHSH 4 -OVERTAKING/PASSING 10-PARKEB 15-WALKING,RANNING, 20-OTHERNON-MOTORISTACTIONS JOGGING, PLAYING 21-STANDING OUTSIDES - BOTH STRIKING S - MAKING RIGHTTARN 11-SLOWING OH STOPPED

& STRUCK 6-MAKING LEFT TURN INTRAFFIC 16-WORKING DISABLED VEHICLE

9-OTHER / UNKNOWN 12 -DRIVERLESS 17-PUSHING VEHICLE 99-OTHER? UNKNOWN

1- NONE 7-LEFT OF CENTER 13-IMPROPER START FROM A 17-VISION OBSTRUCTION 21- LYING IN ROAD W’AY

2- FAILURETOYIELD B- FOLLOWINGTKD CLOSE /ACEA PARKED POSITION OH-OPERATING DEFECTIVE 22-NOT DISCERNIBLE14-STOPPED OR PARKED EQUIPMENT 22-OPENING DOOR INTOof 3-RAN RED LIGHT 9-IMPROPER LANE CHANGE

ILLEGALLY4-RAN STOP SIGN 10-IMPROPER PASSING 19- LOAD SHIFTINGWALLING/ ROADWAY

CBNTRIIBTING 1S-SWERVINGTOAVOID SPILLING 99-OTHER IMPHOPEMACTIONEIRCIMSTHHCESSANSAFESPEED 11-DROVEOFFR00116-WRONGWAY 20-IMPRDPEDCMISSING

6-IRPROPERTURN 12-IMPROPER BACKING

SEQUENCE OF EVENTS

COLLISION WITH FOXED OBJECT — STRUCK31-GUARDRAIL END 37-TRAFFIC SIGN POST 43-CURB32-PORTABLE BARRIER 30 -OVERHEAD SIGN POST 44-DITCH33-MEDIAN CABLE BARRIER 39-LIGHT? LUMINARIES 45-EMBANKMENT

SUPPORT 46-FENCE40- UTILITY POLE 47- MAILBOK41-OTHER POST, POLE 4B-TREE

DR SUPPORT49-FIRE HYDRANT

42-CULVERT

UNIT H OWNER NAME: LAST, FIRST, MIDDLE I2AMEHS ONIVERI

ci-OWNER ADDRESS: STREET, CIT/C STATE, ZIP INAMEAS ORIVERI

COMMERCIAL CARRIER: NAME, ASIMESS, CITY, STATE, ZIP

OWNER PHONE: IH:USEERS-A::oE ISAW.EASDRINRRI

I I I I I , I

LOCAL REPORT NUMBER

IJI//I/[0161/I I

COMMERCIAL CARRIER PH ONE: INC_iCE INCA cc:E

DAMAGE SCALE

1- NDNE 3- FUNCTIONAL DAMAGE

I I 2- MINOR DAMAGE 4-DISABLING DAMAGE

9-UNKNOWN

DAMAGED AREA(SIINDICATE ALL THAT APPLY

23- PEDESTRIAN / SKATER

24 -WHEELCH6IB /ANYTYPEI

25-OTHER NON-MOTORIST

26- BICYCLE

27-TRAIN

99-UNKNOWN OH HIT/SKIP

12 12 12

M93 9 3 M S 9

Q - ND DAMAGE E 0] D - UNDERCARRIAGE [14]

LI-TOP [13] D-ALLAREAS [151

D-UNITNOTATSCENE [161

INITIAL POINT OF CONTACT

0-NODAMAGE 14-UNDERCARRIAGE

3 1-12- REFERTO UNIT 15-VEHICLE NOT AT SCENEDIAGRAM 99 UNKNOWN

13-TOP

TRAFFIC

TRAFFIC WAY FLOW1-ONE-WAY

2 -

6-EQUIPMENT FAILURE

7 -SEPAMATIONOFUNITS

B-RANDFFRUADRIGHT

9-RANDFFROADLEFT

10-CROSS MEDIAN

2 1 - OVERTURN/ROLLOVER

2 - FIRE/EKPLDSIDN

3-IMMERSION2] I / 4-JACKKNIFE

S - CARGO/EQUIPMENTLOSS OR SHIFT

II I I

25 -IMPACTAHENUATOB41 I I /CRASHCUSHION

26-BRIDGE OVERHEADSTRUCTURE

TRAFFIC CONTROL

1 - ROUNDABOUT 4-STOP SIGN

2- SIGNAL S - YIELD SIGN

3-FLASHER 6-NOCDNTRDL

NON - CO L LI SID N11-CROSS CENTERLINE —

OPPOSITE DIRECTION OFTRAVEL

12-DOWNMILL RUNAWAY

13-OTHER NON-COLLISION

14- PEDESTRIAN15-PEDALCYCLE

#OFTHRDUGH LANESON ROAD

16-RAILWAY VEHICLE17-ANIMAL — FARM10-ANIMAL — DEER19-ANIMAL — OTHER20-MOTOB VEHICLE IN

TRANSPORT

21-PARKED MOTORYEHICLE

RAIL GRADE CROSSING

1- N ST INVOLVED

2 - INOOLVED-ACTIYE CROSSINGIJ

- INVOLVED-PASSIVE CROSSING

I 34-MEDIAN GUARDRAIL27-BRIDGE PIER URABUTMENT BARRIER20-BRIDGE PARAPET 3S-MEDIAN CONCRETE

61 I I 29-BRIDGE RAIL BARRIER

30-GUARDRAIL FACE 36-MEDIAN OTHER BARRIER

I 7 I FIRST HARMFUL EVENT MOST HARMFUL EVENT

22-WORK ZONE MAINTENANCEEQUIPMENT

3-STRUCK BY FALLING,SHIFTING CARGO ORANYTHING SET IN MOTIONBAA MOTOR VEHICLE

24-OTHER MOVABLE OBJECT

SO-WORK ZONE MAINTENANCEEQUIPMENT

51-WALL

52-BUILDING53-TUNNELS4-OTHER FIKDD OBJECT99-OTHER/UNKNOWN

UNIT / NON-MOTDRIST DIRECTION

1-NORTH 5- NDBTHEAST

2 - SOUTH 6 - NORTHWEST

FROM LJ TO 3-EAST 7-SOUTHEAST

4 - WEST B - SOUTHWEST

9-OTHER/UNKNOWN

UNIT SPEED

ID I

DETECTED SPEED

Lj

1- STATED? ESTIMATED SPEED

2-CALCULATDD/EDB

3-UNDETERMINEDPDSTED SPEED

-3 —

HSYO3D4 OH?U 1/19 [760-0620] PAGE 20F

OHIO DEPAHThENT U NIT

UNIT # OWNER NAME: LAST, FIRST, MIDDLE 5AHE4:OMVER)

021OWNER ADDRESS: STREET, CITY, STATE, ZIP ZAOEAS DRTVEHI

COMMERCIAL CARRIER: NAME,ASDRESS, CITY, STATE, DIP III

LP STATE I LICENSE PLATE # I VEHICLE IOENTIFICAnON # I VEHICLE YEAR I VENICLE MAKE0i/Jj4’j 85 /JHM&b/3/1//4’,8/sO,c i,3/z/L. O/o8//y&//4

INSIRANCE INSURANCE COMPANY INSURANCE POLICY 1! I COLOR I VEHICLE MODELIEVERInED I (,E,’co I v/8flzs?1 //LQfI t’r

TYPE IF USE I US DOT # I TOWED BY:CSMPASY NAME

C IN EMERGENCY I IC COMMERCIAL GOVERNMENT RESPONSE I i i I IHAZARDOUS MATERIAL

INTERLOCK I #OCCUPANTSVEHICLE WEIGHT GVWRIGCWR

C MATERIAL CLASS # PLACARO 10 #

EQUIPPED c r / 2 - 10,001-261< LBS. C PLACARD I_____ I IIC DEVICE NIT/SKIP UNIT I 1 - 10I< LBS. RELEAGED

L_J 3 - >26K LBS.

PASSENGER CAR 7-MOTORCYCLE 2-WREELED 12 -GOLF CART lI-LIMO (LIVEMYTEHICLE) 23-PEDESTRIAN/SKATER

2- PASSENGERYAN (MINIYAN) I - MOTORCYCLE3-WMEELED 13-SNOWMOIILE 09-00S116+ PASSENGERS) 24-WHEELCHAIR (ANYTYPE)3- SPORT UTILITYVEHICLE 0- AOTOCYCLE 14-SINGLE UNITTRUCK 20-OTHER VERICLE 25-OTHER NON-MOTORIST

UNETTYPE 4- PICKOP SO-MOPE000 MOTORIZED 15-SEMI-TRACTOR 26-HEAOYEQUIPMENT 26-BICYCLE

5- CARGOYAN BICYCLE 16-FARM EQUIPMENT 22-ANIMAL WITH HIDER DR 27-TRAIN

6-VAR (9-15 SEATS) 10 -ALLTERRAINVEOICLE 17- MOTORHOME ANIMAL-DRAWN VEHICLE 99-UNKNOWN OR HIT/SKIP

11 BFTRAILING UNITS(ATY/UTY)

WASYEHICLEOPERATING IN AUTDNDMDUS 0- NOAUTUMATION 3- CONDITISNALAUTOMATION 9-UNKNOWNMODE WHEN CRASH OCCUMMERT c) 1 - DRIVERASSISTVNCE 4 - HIGH AUTOMATION

L_ZJ 0-YES 2- NO 9-OTHER! UNKNOWN A 2 - PADTIALA6TOMATION S - FULLAUTOMATIONUTINDMIUSMIDE LEVEL

S - NONE 6- lOS— CHARTEBTOUR 11-FIRE 16-FARM 21- MAIL CARRIER

2 -T6VI 7 -BUS-INTEDCI9V 12-MILIT6RY 17-MOWING 99-OTHER/UNKNOWN

1 - ELECTROVIC RIDE SHARING I - BUS — SHUTTLE 13-POLICE 00-SNOW’ REMOVALSPECIALFUNCTION - SCHOOLTRANSPORT 9-BUS—OTHER 14-PUBLIC UTILITY 19-TOWING

S - BUS —TMAVSIT/COVMLTER 10 -AMIULANCE 15-CONSTRUCTION EQUIPMENT 25-SAFETY SERVICE PATROL

1 - NO CARGO BTOYTTPE 3- VEHICLETUWING 6NOTHER S - INTEMMODAL CONTAINER B - POLE 12-CONCRETE MIUER

jJj

/NOTAPPLICAILE MOTOR VEHICLE CHASSIS 9 -CARGOTUNK 13-AUTOTRANSPORTERCARGO 2- 165 4-LOGGING 6- CARGO VAN,’ENCLOSED IOUBODY 10-FLATBED 14 -GARBAGE/REFUSE

7-GRAIN/CHIPS/GRAVEL 11-DUMP 99-OTHER/UNKNOWNTYPE

1-TURN SIGNALS 4-BRAKES 7-WORN OR SLICKTIRES 9 - MOTOROROUBLE 99-OTHER/UNKNOWN

VEHICLE 2-HEAR LUMPS S - STEERING 8- TRAILER EQUIPMENT 10-DISABLED FROM PRIORDEFECTS 3-TAIL LAMPS 6-TIRE OLOWOUT DEFECTIVE ACCIDENT

1- INTERSECTION — HARKED 3-INTERSECTION—OTHER

LL_J CROSSWALK 4-MIEDLOCK—HARKEDNON-MITIRIST 2-INTERSECTION — UNMARKED CROSSWALKLOCATION CROSSWALK 5-TRAVEL LANE—OTH:R LA:An:RAT IMPACT

6- BICYCLE LANE 9 - MEDIAN/CROSSING ISLAND 12 -FIRST RESPONDER

7- SAUULDER/ HOADSIEE 10-DRIVEWAY ACCESS AT INCIDENT SCENE

I -SIDEWALK 11-SHARED USE PATHSOR 99-OTHER/UNKNOWN

TRAILS

1- NON-CONTACT 1- STMAIGHTAAEAD 7 - MAKING U-TURN 13 -NEGOTIATING A CURVE 10 -APPROACHING

2- NON-COLLISION 2 - BACKING B - ENTERING TRAFFIC LANE 14- ENTERING OR CROSSING OR LEAVING VEHICLE

LLJ 3- STRIKING LLLLJ 3- CHANGING LANES 9- LEAVINGTRAFFIC LURE SPECIFIED LOCATION 19-STARRING

ACTION 4- STRUCK PRE-ERASH 4 -OVERTAKING/PASSING 10-PARKED 15-WALKING,RUNNING, 20-OTHER NON-MOTORIST

S - BOTH STRIKINGACTIONS

S - MAKING RIGMTTURN 11 -SLOWING 00 STOPPEDJOGGING, PLAYING 21 -STARRING OUTSIDE

A STRUCQ 6- MAKING LEFTTUMR INTRAFFIC 16-WOROING DISABLED VEHICLE

9- OTHER! UNKNOWN 12 -DRIVERLESS 17- PUSHING VEHICLE 99 -OTHER! UNKNOWN

1- NONE 7- LEFT OF CENTER 13 -IMPROPER START FROM A 17-VISION OBSTRUCTION 21 -LYING IN ROADWAY2- FAILURETO YIELD 8 - FOLLO WING TOO CLOSE /ACDO PARKED POSITION 08 -OPERATING DEFECTIVE 22 -NOT DISCERNIBLE

D4-STOPPEDOMFARKED EQUIPMENT 23-OPENING 000MINTOc’/ 3RANREDLIGHT 9IMPROFERLANECHANGEILLEGALLY

4- RAN STOP SIGN DO-IMPROPER PASSING 19-LOAD SHIFTING/FALLING! ROADWAYEINTRIBITING 15 -SWERAINGT0 OVOID SPILLING 99 -OTHER IMPOOPEMACTION5- UNSAFE SPEED 10-DROVE OFF ROAREIRCUNSTONCES 16-WRONG WAY 20-IMPROPER CROSSING

6- IMPRAPERTURN 12 -IMPROPER DOCKING

NON-COLLISION11-CROSS CENTERLINE —

OPPOSITE DIRECTION OFTRAVEL

02-DOWNHILL RUNAWAY03-OTHER NON-COLLISION14- PEDESTRIAN15- PEDALCYCLE

16-RAILWAY VEHICLE

17-ANIMAL — FARMlB-ANIMAL — DEER

_________

19-ANIMAL — OOHEM20- MOTOR VEHICLE IN

TMANSPORT3/ / 21-PARKEOMOTORVEHICLE

COLLESEON WITH FIXED OBJECT — STRUCK25-IHPACTAUENOATUR 3D-GUARDRAIL END 37-TRAFFIC SIGN POST 43-COMB

L___1____J (CRASH CUSHION 32-PORTABLE BARMIER 30-OVERHEAD SIGN POST 44-DITCH26- BRIDGE OVERHEAD 33 -MEDIAN CABLE BARRIER 39-LIGHT! LUMINARIES 4S-EMBANKMENT

STRUCTURE5 /_________

34-MEDIAN GUARDRAIL SUPPORT 46-FENCE27-BRIDGE PIER OR ABUTMENT BARRIER 40-UTILITY POLE 47- MAILBOO28-BRIDGE PARAPET 35- MEDIAN CONCRETE 41-OTHER POST, POLE 48-TREE

6/ / 29-BRIDGE RAIL BARRIER OR SUPPORT49-TIDE HYOMANT

30-GUARDRAIL FACE 30-MEDIAN OTOEM BARMIER 42-CULVERT

/ / FIRST HARMFUL EVENT MOST NARMFUL EVENT

DAMAGE SCALE- 1-NONE 3-FUNCTIONAL DAMAGE

/ _/ 2-MINOR DAMAGE 4-DISABLING DAMAGE

9-UNKNOWN

DAMAGED AREA(S)INDICATE ALL THAT APPLY

12 12ii 1 11

jS

12B

C-NO DAMAGECO] C-UNDERCARRIAGE L14]

UNIT/ NON-MOTORIST DIRECTION

- NORTH S-NORTHEAST

2 - SOUTH 6 - NORTHWEST

FROM L.ZJ TO L_IZJ 3-EAST 7-SOUTHEAST

4 - WEST I - SOUTA WEST

9-OTHER / UNKNOWN

OWNER PHONE: iNCLUDE AREA CAEE

I I I I I I

LOCAL REPORT NUMBER

I /%II/IOI91 I I

COMMERCIAL CARRIER PHONE: I%DL’JDE AREA CSAE

I I . I I I

12

1ofHs/\2

S

C-TOP C131 D-ALLAREAS CON)

Q - UNIT NOT AT SCENE [16)

SEQUENCE or EVENTS

INITIAL POINT IF CONTACT0- NO DAMAGE 14- UNDERCARRIAGE

( Q. 1-12 - REFER TO UNIT 15-VEHICLE NOT AT SCENE

99- UNKNOWN13-TOP

TRAFFIC

1 2 1 - OVCDTURN/MOLLOVEM

2 - TIDDEOPLOSION

3-IMMERSION21 4-JACKKNIFE

5- CORGO/EOUIPHCNTLOSS OR SHIFT

TRAFFIC WAY FLOW

1-ONE-WAY

12-TWO-WAY

6- EQUIPMENT FAILURE

7 - SEPARATION OF UNITS

8-MAN OFF MOOD RIGHT

9-RAN OFF ROOD LEFT

10-CROSS MEDIAN

TRAFFIC CONTROL

- ROUNDABOUT 4-STOP SIGN

2 - SIGNAL S - YIELD SIGN

3-FLASHED 6-NDCONTRDL

#DF THROUGH LANESON ROAD

LYJ

RAIL GRADE CROSSING

1-NOT INVOLVED

2 - INVOLVED-ACTIVE CRDSSINGLJ

- INVOLVED-PASSIVE CRDSSING23-WORK DONE MAINTENANCEEIUIPM [NT

23-STRUCK BY TOLLING,SHIFTING CARGO ORANYTHING SET IN MOTIONDYA MOTOR VEHICLE

24 -OTHEM MOVABLE OBJECT

SO-WORK DONE MAINTENANCEEQUIPMENT

Si-WALL

52- BUILDING53-TUNNEL

S4-OTHER TIOCD OBJECT99-OTHER/UNKNOWN

UNIT SPEED DETECTED SPEED

1- STATED / ESTIMATED SPEED

2-CALCULATED/COB

3-UNDETERMINEDPOSTED SPEED

-2cIIF

HBYB3O4 OH1U 1/19 1760-0020] PAGE 3 OF8

Y!’i U NIT

1- NON—CONTACT

2- NON—COLLISION

20-IMPACT AHENOATOR41 I I !CRASH CUSHION

26-BRIOGE OVERHEAOSTRUCTURE

COLLISION WITH FIXED OBJECT — STRUCK30 -GUARORAIL ENI 37-TRAFFIC SIGN POST 43-CURB32 -PORTABLE BARRIER 31 -OVERHEAD SIGN POST 44 -OITCH33 -MEOIAN CABLE BARRIER 39- LIGHT! LUMINARIES 45 -EMUANKMENT

SUPPORT 46-FENCE40- UTILITY POLE 47- MAILBOU40-OTHER POST, POLE 40-TREE

OR SUPPORT49-FIRE HOORANT

42-CU LYERT

12 12 12

D-NO DAMAGE [0] D-UNOERCARRIAGE E143

LI-TOP EU] 0-ALLAREAS ElSI

D-UNITNDTATSCENE E16]

INITIAL POINT OF CONTACT

0- NO OAMAGE 14- UNDERCARRIAGE

1-12 - REFER TO UNIT 15-VEHICLE NOT AT SCENEDIAGRAM 99- UNKNOWN

UNIT/NON-MOTORIST OIRECTION

- NORTH 5-NORTHEAST

2-SOUTH 6-NORTHWEST

FROM LJ TO L_ 3 - EAST 7 - SOUTHEAST

4 - WEST B - SOUTHWEST

9 -OTHER!UNKNUWN

4

UNUT# OWNER NAME: LAST, FIRST, MIDSLE )SAMEVSORIVEE) OWNER PHONE: IRCLUIEARSS ISlE SVMEASSRIVER)

L°I’—I I I I I I I I

OWNER ADDRESS: STREET, CITY, STATE, ZIP )5EMEAS DRIVER)

COMMERCIAL CARRIER: NAME,ASSRESS, CITY, STATE, ZIP COMMERCIAL CARRIER PHONE: ISILUDEAVEA CODE

I I i I I I I

LP STATE LOCENSE PLATE # VEHICLE IDENTIFICATION # - VEHICLE YEAR VEHICLE MAKE

Cw S’S 5792 I3M, Z1%Af1 ,&J, 4758k gj /01 /INSURANCE INSURANCE COMPANY INSURANCE POLICY # COLOR VEHICLE MODEL

VERIFIED Ceico 932/948309 WJ//TE SOAJOTA• USDOT#

LOCAL REPORT NUMBER

I I I I )

DAMAGE

DAMAGE SCALE1- NONE 3- FUNCTIONAL DAMAGE

I J 2- MINOR DAMAGE 4- DISABLING DAMAGE

9- UNKNOWN

DAMAGED AREA(S)INDICATE ALLTHAT APPLY

TYPE OF USE I I TOWED BY:CSMPANY SAME

G IN EMERGENCY I IHAZARDOUS MATERIAL

G COMMERCIAL DGOVERNMENT RESPONSE I I I I I I I

EQUOPPED‘‘ I I____ 3->26KL0S. C PLACARD cI I I

ONTERLOCK #OCCUPANTSVEHIELEWEIGHTGVWR/GCWR

ID MATERIAL ELASS# PLACARDIO#Ii DEVICE F] HIT/SKIP UNIT

/1 - sOOK LBS. RELEASED/ 2 - 10,001-26K LOS

I - PASSENGER CAR 7- MOTORCYCLE 2-WHEELED 02 -GOLF CART 00 -LIMO ILIOERY VEHICLE! 2] -PEBES0010N !SKATER2- PASSENGER VAN IMINIVANI U - MOTORCYCLE 3-WHEELED 0] -SNOWMOOILE 09 -BUS 106+ PASSENGERS! 24 -WHEELCHAIR !ANYTYPEI

LU__LJ 3- SPORT UTILITYYEOICLE 9- AUTOCYCLE 04 -SINGLE UNITTRUCK 20 -OTHER VEHICLE 25 -OTHER NON-MOTORISTUNIT TYPE 4- PICK UP 00-MOPED OR MOTORIZED 15 -SEMI-TRACTOR 20 -OEAVY EQUIPMENT 26-BICYCLE

5- CARGO VAN BICYCLE 06 -FARR EQUIPMENT 22 -ANIMAL WITH RIDER SR 27 -TRAIN

U - VAN 19-OS SEATS! 00 -ALLTERRAIN OEHICLE 07 -MOTORHOME ANIRAL-ERAWNYEHICLE 99- UNENOWN OR HIT!SKIP

L.LJ 41 OFTRAULING UNITSIATV!UTO!

WAS VEHICLE OPERATING IN AUTONUMUUS 0 - NO AUTOMATION 3- CONDITIONAL AUTOMATION 9- UNKNOWNMODE WHEN CRASH OCCURRED? 0 - ORIVERASSISTANCE 4- HIGH AUTOMATION

L_f?J 1 -YES 2- NO 9- OTHER! UNKNOWN AUTONOMOUO 2- PARTIALAUTOMATION S - FULLAUTOMAVIONMODE LEVEL

0 - NONE U - BUS - CHARTEETOUR 00 -FIRE OU -FARM 20 -MAIL CARRIER

2- TAXI 7 - BUS -INTERCITY 02 -MILITARY 07 -MOWING 99 -OTHEUI UNKNOWN

3 - ELECTRONIC RIDE SHARING B - BUS — SHUTTLE 0] -POLICE DB-SNOW REMOVALSPECIALFUN CTID N - SCHOOLTRANSPORT 9- BUS —OTHER 04 -PUBLIC UTILITY DO-TOWING

5- BUS—TRANSIT!COMMUTEO 00-AMBULANCE B-CONSTRUCTION EQUIPMENT 20-SAFETO SERVICE PATROL

0 - NO CARGO BODYTYPE 3- VEHICLUTOWINGANOTHER 5- INTERM000L CONTAINER 0 - POLE 02-CONCRETE MIOER4j] !NOTAPPLICABLE MOTOR VEOICLE CHASSIS 9- CARGOTANK 03-AUTOTRANSPORTERCARGO 2- BUS 4- LOGGING U - CARGO VAN!ENCLOSEO IOU 00-FLAT BED 04 -GARBAGE’REFLSEB 0 DY

7 - GRAIN!CMIPS!GRAAEL 00-OUMP 99 -OTHER! UNKNOWNTYPE

0 - TURN SIGNALS 4- BRAKES 7 - UKORN OR SLICKTIRES 9 - MOTORTR000LE 99 -OTHER! UNKNOWN-

VEHECLE 2 - HEAD LAMPS 5- STEERING U - TRAILER EQUIPMENT 00-DI5UBLED FROM PRIORDEFECTS 3 - TAIL LAMPS 6 - TIRE BLOWOUT DEFECTIVE ACCIDENT

0- INTERSECTION — MARKEB 3 - INTERSECTION - OTHER 6- BICYCLE LANE 9 - MEDIANICROSSING ISLAND 02 -FIRST RESPONDERL_1J CROSSWALK 4- MIDBLOCK— MARKER 7 - SHOULDER! ROADSIDE 00 -DRIVEWAY ACCESS AT INCIDENT SCENE

NUN-MITIRIST 2- INTERSECTION — UNMARKED CROSSWALK U - SIDEWALK 00 -SHARED USE PATHS OR 99 -OTHER! UNKNOWNLOCATION CROSSWALK 5 -TRAVEL LANE—DIRER LSIATIIN TRAILSAT IMPACT

LJJ

ACTION

0- STRAIGMTAHEAD 7 - MAKING U-TURN

2- BACKING U - ENTERINGTRATFIC LANE

3-STRIKING LLLZ 3 - CHANGING LANES

4- STRUCK PRE-CRHSH -OVERTAKING!PASSING

5- BOTH STRIKINGAETIDNS

5-MAKING RIGHTTURN&STRACK U - MAKING LEFTTURN

9-OTHER! UNKNOWN

- LEAVINGTRAFFIC LANE

00-PARKED

00-SLOWING DR STOPPEDIN TMAFFIC

02-BRIVERLESS

03-NEGOTIATING A CURVE

04- ENTERING OR CROSSINGSPECIFIED LOCATION

OS-WALKING, RUNNING,JOGGING, PLAYING

06-WORKING

07- PUSHING VEHICLE

lU-APPROACHINGDR LEAVING VEHICLE

09-STANDING

20-OTHER NON-MOTORIST

20- STANDING OUTSIDEDISABLED VEHICLE

99-OTMER!UNKNOWN

0- NONE 7- LEFT OF CENTER 03 -IMPROPER START FROM A 07-VISION OBSTRUCTION 20- LYING IN ROADWAY2- FAILURE TO YIELD U - FOLLOWING TOO CLOSE! ACOA PARKED POSITION UO - OPERATING DEPECTIVE 22- NOT DISCERNIBLE

B4 -STOPPED OR PARKEO EQUIPMENT 2] -OPENING DOOR INTO12/ 3-RANREDLIGHT Q-IHPROPERLANECMANGEILLEGALLY

4- RAN STOP SIGN 00-IMPROPER PASSING 09- LOAD SHIFTINGJFALLINGI ROADWAYCONTRIBUTING OS -SWERVINGTOAVOID SPILLING 99 -OTHER IMPROPERACTIONS-UNSAFE SPEED 00-DROVE OFF ROADCIRCUNBTHNEES 06-WRUNG WAY 20 -IMPROPER CROSSING

U- IMPROPERTURN 02-IMPROPER BACKING

SEQUENCE OF EVENTS

13-TOP

TRAFFSC

DI 21C1 3 -OVERTURN!ROLLOVER

2 - FIRUEOPLOSIDN

3 - IMMERSION21 I 4-JACKKNIFE

5- CARGO!EQUIPMEATLO SS OR SHIFT

31 I

TRAFFIC WAY FLOW

0-ONE-WAY

2 2-TWO-WAY-

A - EQUIPMENT FAILURE

7 - SEPARATION OF UNITS

B-RANOFFROADRIGMT

9-RANOFFROADLER

00-CROSS MEOMN

TRAFFIC CONTROL

0 - ROUNDABOUT 4-STOP SIGN

2 - SIGNAL S - YIELD SIGN

3-FLASHER 6-NOCONTROL

NON-COLLISION10-CROSS CENTERLINE —

OPPOSITE DIRECTION OFTRAVEL

02-DOWNHILL RUNAWAY03-OTHER NON—COLLISION04-PEDESTRIANIS -PEDALCYCLE

OF THROUGH LANESOH ROAD

16- RAILWAY VEM IC LE17-ANIMAL — FARM00-ANIMAL — DEER09-ANIMAL—OTHER20- MOTOR VEHICLE IN

TRANSPORT

21-PARKED MUTOR VEHICLE

RAIL GRADE CROSSING

l-NDT INVOLVED

2 - INVOLVED-ACTIVE CROSSING

3 - INVOLVED-PASSIVE CROSSING22-WORK DONE MAINTENANCEEQUIPMENT

23-STRUCK BY FALLING,SHIFTING CARGO ORANYTHING SE IN MOTiONBYA MOTOR VEHICLE

24-OTHER MOVABLE OBJECT

SO-WORK DONE MAINTENANCEEQUIPMENT

51-WALL52-BUILDING53-TUNNEL

54-OTHER FIUED OBJECT99-OTHER!UNUNOWN

SI I I 34-MEDIAN GUARDRAIL27-BRIDGE PIER ORABUTMENT BARRIER21-BRIDGE PARAPET 35-MEDIAN CONCRETE

SI I j 29-BRIDGE RAIL BARRIER30-GUARDRAIL FACE 36- MEDIAN OTHER BARRIER

I / I FIRST HARMFUL EVENT L__L MOST HARMFUL EVENT

UNIT SPEED DETECTED SPEED

J—J0 -STATED!ESTIMATEDSPEEO

2- CALCULATED!EDR

3- ANDETERMINEDPOSTED SPEED

I 2131

HSYO3O4 OH1U 1/19 [760-0820] PAGE 9 OF8

‘LV— 00)0 DEPARTMENT

E6 0.7Z NIT

25-IMPACT ATTENUATOR41 I I ICRASH CUSHION

26-BRIDGE OVERHEADSTRUCTURE

NON-C OLLISIONDO-CROSS CENTERLINE — 06-RAILWAY VEHICLE

OPPOSITE DIRECTION OF 07-ANIMAL — PARMTRAVEL

08-ANIMAL— DEER12-DOWNHILL RUNAWAY 09-ANIMAL — OTHER13-OTHER NON—COLLISION 20-MOTOR VEHICLE IN14-PEDESTRIAN TRANSPORTDS-PEOALCYCLE 20-PARKED MOTORHEHICLE

COLLOSDON WITH FIXED OBJECT — STRUCK31-GUARDRAIL END 37-TRAFFIC SIGN POST 43-CURB32-PORTABLE BARRIER 30-OVERHEAD SIGN POST 44-DITCH33-MEDIAN CABLE BARRIER 39-LIGHT! LOMINARIES 4S-EMBANKMENT

SUPPORT 4A-FENCE40-UTILITY POLE 47-MAILBOO41-OTHER POST, POLE 40-TREE

OR SAP P0 RT49-FIRE HADRANT

42-CULVERT

DAMAGE SCALE- 1-NONE 3-FUNCTIDNALDAMAGE

I I 2- MINOR DAMAGE 4- DISABLING DAMAGE

9-UNKNOWN

DAMAGED AREA(S)INDICATE ALL THAT APPLY

12

UNIT I NDN-MBTORDST DIRECTION

- NORTH S - NORTHEAST

2-SOOTH 6-NORTHWEST

FROM LJ TO LLJ 3 - EAST 7 - SOUTHEAST

4 - WEST B - SOUTHWEST

9-OTHER/UNKNOWN

DETECTED SPEED

1- STATEOI ESTIMATED SPEED

2-CALCULATERIERR

3 - RNDETERMINEO

UNIT H OWNER NAME: LAST, FIRST, MIDDLE QSAAESSEVWE+

/. VA A/Ca,t’E,i/ ren’k-Es INC

COMMERCIAL CARRIER: NAME,ASIRESS, CITY, STATE, ZIP

OWNER ADDRESS: STREET CITY STATE, ZIP IQSAOE AS ERIVEM

/OSLS,k’M/SHAA/ A’b VEwEuf V OW %4s 2P7t

4.

OWNER PNONE: MaSSE MW 7SCE SAME AS SHIVER)

LOCAL REPORT NUMBER

f9I//IO?I I

LP STATE LICENSE PLATE # VEHICLE IDENTIFDCATION # VEHICLE YEAR I VEHICLE MAKE

OIL PJ&22ia

EIMMERCIAL CARRIER PHONE: ISCLVEEARSA COSE

I I I I I I I I I

12

lt

- — - -

—

INSHRANEE I INSURANCE COMPANY I INSURANCE POLICY # I COLOR I VEHICLE MODELIflIVERIPIEI tvErnc’t b 1k/Lg/S33t, /VliROo4/iegRA

TYPE OF USE US DOT # I TOWED BY: CSMFANY RAMEIN EMERGENCY ICOMMERCIAL GOVERNMENT Ei RESPRNSE I I I I I

HAZARIRUS MATERIALINTERLOCK I #OCCUPANTS

VEHICLE WEIGHT GVWRIGCWRMATERIAL CLASS # PLACARD ID #

1 2 - 10,001 -26K LAS.U DEVIEE HIT/SKIP UNIT1 - 1OK LAS.

RELEASEDEQUIPPED 0/ LLJ 3->26KLRS. PLACARD I I I

0 - PASSENGER CAR 7 - MOTORCYCLE 2-WHEELED 12 -GOLF CART 10- LIMO /LIHERYYEHICLE/ 23-PEDESTRIAN/ SKATER2 - PASSENGER VAN /MINIVAN/ H - MOTORCYCLE 3-WHEELER 13- SNOWMOBILE 19 -BUS /16+ PASSENGERS! 24 -WHEELCHAIR IANYTYPEIkij 3- SPORT UTILITYHEHICLE 9- AUTOCYCLE 14-SINGLE UNITTRUCK 20-OTHERVEHICLE 25-OTHER NON-MOTORIST

UNIT TYPE 4 - PICK UP 00 -MOPER OR MOTURI2EO 15 -SEMI-TRACTOR 20- HEAVY EQUIPMENT 26-BICYCLES -CURGOHAN BICYCLE 16-FARM EQUIPMENT 22-ANIMAL WITH RIDER CR 27-TRAIN6 - VAN 19-OS SEATS! 01 -ALLTERRAIN VEHICLE 17- MUTORHOME ANIMAL-DRAWN VEHICLE 99-UNKNOWN OR HIT/SKIP

1ATYI OTT!

LQJ # IFTRAILING UNITS

WASYEHICLE OPERATING IN AUTBNRMRUS 0 - NOAATOMATIOS 3- CONOITIONALAUTOMATION 9- UNKNOWNMODE WHEN CRASH OCCURRED?

I0 - DRIVER ASSISTANCE 4- HIGH AUTOMATION

L_ZJ 1-YES 2-NO 9-OTHER/UNKNOWN AUTIHOMORI 2- PARTIALAUTOMATION S - FULLAUTOMATIONMODE LEVEL

0 - NONE 6- BUS — CHARTEPJTOUR 11 -FIRE 16-FARM 21 -MAIL CARRIER

141L1J2- THAI 7- BUS—INTERCITY 12-MILITARY 07-MOWING 99-OTHER/UNKNOWN3- ELECTRONIC RIDE SHARING B - BUS — SHUTTLE 03- POLICE DO-SNOW REMOVALSPECIAL

FUNCTION 4- SC000LTRANSPORT 9- RUS—OTHER 14-PUBLIC UTILITY 19-TOWING

S - BUS—TRANSIT/COMMUTER 00-AMBULANCE 15-CONSTRUCTION EQUIPMENT 20-SAFETYSERYICE PATROL

1 - NO CARGO RADYTYPE 3 - VEHICLETOWING ANOTHER S - INTERM010L CONTAINER I - POLE 12 -CONCRETE MITERLZLZJ / NOTUPPLICABLE MTTORYEHICLE CHASSIS 9- CARGOTANK 13-AUTQTRANSPRRTERCARGO 2- BUS 4- LOGGING A - CHRGOYAN/ENCLOSEO IOU 00-FLATRER 14-GARIHGDREFUSEBODYTYPE 7 - GROIN/CHIPS/GRAVEL 00-DUMP 99-OTHER/UNKNOWN

1- TURN SIGNALS 4- BRAKES 7- WORN OR SLICKTIRES 9- MOTORTROURLE 99-OTHER/UNKNOWNI_VEHICLE 2- HEAD LAMPS S - STEERING I - TRAILER EQUIPMENT 00-DISABLED FROM PRIORDEFECTS 3 - TAIL LAMPS 6- TIRE BLOWOUT REFECTIYE ACCIOENT

12ii

12

1

A :1’-!S 4H

A

A

1- INTERSECTION — MARKER 3 - INTERSECTION —OTHER A - BICYCLE LANE 9 - HEllOS/CROSSING ISLAND 12 -FIRST RESPONDER_j CROSSWALK 4 - MIDBLOCK — MARKER 7 - SHOULDER / ROARSIRE 10- DRIVEWAY ACCESS AT INCIDENT SCENE

NIN-HITIRIST 2- INTERSECTION - UNMARKED CROSSWALK B - SIDEWALK 11 -SHARER USE PATHS OR -OTHERI UNKNOWNLOCATION CROSSWALK 5 -TRAVEL LANE—OThER LSCRSSR TRAILSAT IMPAET

R93 R 3 R 3 0 3

D-NODAMAGE[0J LI-UNDERCARRIAGE [14]

C-TOP [13] D-ALLAREAS [15]

D-UNITNDTATSCENE [16]

1-NON—CONTACT 0 -STRAIGHTAHEAD 7 - MAKING U-TURN 03-NEGOTIATINGHCURVE 10-APPROACHINGT3) 2- NON—COLLISION 2- HACKING B - ENTERINGTRAFFIC LANE 04 -ENTERING OR CROSSING OR LEAVING VEHICLE

L_ZJ 3- STRIKING L2I_LJ 3- CHANGING LANES 9- LEAVINGTRAFFIC LONE SPECIFIED LOCATION 19-STANOING

ACTION 4- STRUCK PRE-EROSH - OVERTAKING/PASSING 00- PARKED OS -WALKING, RUNNING, 20-OTHER NON-MOTORISTACTIONS JOGGING, PLAYING 21- STANOING OUTSIDES - BOTH STRIKING S - MAKING RIGMTTARN 01 -SLOWING OR STOPPED

A STRUCK 6- MAKING LEFTTORN INTRAFFIC 06 -WORKING DISOHLEDYEHICLE

9- OTHER / UNKNOWN 02- DRIVERLESS 17 -PUSHINGYEHICLE 99 -OTHER I UNKNOWN

INITIAL POINT OF CONTACT0-ND DAMAGE 14- UNDERCARRIAGE

/1 4 1-12 - REFERTO UNIT 15-VEHICLE NOT AT SCENEDIAGRAM

99- UNKNDWN13-TOP

1- NONE 7 - LEFT OF CENTER 03-IMPROPER START FROM A 07 -VISION OBSTRUCTION 21- LYING IN ROADWAY2- FAILURETOYIELD I- FOLLOWING TOO CLOSE /ACDA PARKED POSITION 00-OPERATING OEFECTIVE 22- NOT RISCERNIBLE

04-STUPPEDOR PARKEI EQUIPMENT 23-OPENING WORINTOQ9 3-RONREILIGHT 9-IMPROPERLONECHANGEILLEGALLY

4- RAN STOP SIGN 00 -IMPROPER PASSING 09 -LOAD SHIFTING/FALLING! ROADWAYCINTRIIITING 05 -SWERVINGTO OYOID SPILLING 99-OTHER IMPRIPERACTION5- UNSAFE SPEEO 01-DROVE OFF ROADIIRCUMSTIHCES 06-WRONG WAY 25-IMPROPER CROSSING

A - IMPROPERTURN 12 -IMPROPER HACKING

SEQUENCE IF EVENTS

TRAF FEC

SI1-OVERTURN/ROLLOVER

2- FIRUEHPLOSION

- 3-IMMERSION21 -‘CI I 4-JACKKNIFE

S - CARGO/EQUIPMENTLOSS OR SHIFT

31 I I

TRAFFIC WAY FLOW1-ONE-WAY

2 -RKO-WAY

6-EQUIPMENT FAILURE

7-SEPARATIONOF UNITS

I- RAN OFF ROAD RIGHT

9-RANOFFROARLEFT

00-CROSS MEDIAN

TRAFFIC CONTROL

- ROONDAHOUT 4 - STOP SIGN

L—(c—J2 - SIGNAL S - YIELD SIGN

3-FLASHER 6- NO CONTROL

#OFTHROUGH LANESOH RDAD

RAIL GRADE CROSSING

0 - NIT INROLTER

2 - INVOLVED-ACTIVE CROSSING

3 - INVOLVED-PASSIVE CROSSING

Ii I I 34-MEDIAN GUARDRAIL27 -BRIRGE PIER ORAHUTHENT HARRIER2O-IRIRGE PARAPOT 35-MEDIAN CONCRETE

6

_________

29-RRIRGE RAIL HARRIER

30-GUARDRAIL FACE 30-MEDIAN OTHER BARRIER

I / FIRST HARMFUL EVENT L_/_J MOST HARMFUL EVENT

22-WORK ZONE MAINTENANCEEQUIPMENT

23-STRUCK BY FALLING,SHIFTING CARGO ORANYTHING SET IN MOTIONRYA MOTORTERICLE

24-OTHER MOVABLE OHJECT

SO-WORK ZONE MAINTENANCEEQUIPMENT

51-WALL52-HUILRING

53-TUNNEL

54-OTHER FIOEDORJECT99-OTHER! UNKNOWN

UNIT SPEED

13101 I

POSTED SPEED

I I I

HSYB3D4 OH1U 1/19 1700-00201 PAGE

LOCAL REPORT NUMBER

/9/76 cI?L/I

MOTORIST I N ON- M 010 RISTI I

UNIT # NAME; LAST, FIRST, MIDDLE pATE or BIR H AGE GENDER

/, M/v/LL/g /)AJV/VV [!//I7I%lIb1OIH

ADDRESS; STREET, CIT’i STATE,ZIP CONTA PHONE- INCLUDE AREA CODE

31/’1//t’Rsr CT /‘E/JT W qqzq’ 33 93) 2II3_I

INJURIES INJURED EMS AGENCY tNAME) INJUREDTAKENTO MEDICAL FACILITY INAUE,CITYI SAFETY EQUIPMENT SEATING POSITION MR BAG USAGE EJECTION TRAPPED

______

TAKEN USED , QD0T0MANT

I / / /CL STATE OPERATOR LICENSE NUMBER OFFENSE CHARGED LOCAL OFFENSE DESCRIPTION CITATION NUMBER

kS9Oz/3 CODE

CL CLASS ENDORSEMENT RESTRICTION SELECTUPTOT DRIVER ALCOHOL I DRUG SUSPECTED CONDITION ±1’1tuii*1SELECT APTO2 DISTRACTED STATUS• TYPE VALUE STATUS TYPE RESULT ssccm;

fl ALCOHOL MARIJUANA j

/ I I 03 I I I / i OTHER DRUG I I

UNIT # NAME; LAST, FIRST, MIDDLE 1DATE OF BIR H AGE GENDER

0, Z, /sz czyK I // z// 9 z V a

ADDRESS; STREET,CITY, STATE, ZIP CONTArT PHONE - INCLUDE AREA CODE

/7/ C45 Z,? ]Y1/cMY 2// 21/p 5c- 3 8 o 712 I IINJURIES INJURED EMS AGENCY (NAME) INJUREDTAKENT0 MEDICAL FACILITY INAME,CITY) SAFETY EQUIPMENT SEATING POSITION AIR BAG USAGE EJECTIIN TRAPPED

___

TAKEN USED,

QD0TCNT

/ I / /

CL STATE OPERATOR LICENSE NUMBER OFFENSE CHARGED LOCAL OFFENSE DESCRIPTION CITATION NUMBERCODE

,D,J/7/i93o2(OL CLASS ENDORSEMENT RESTRICTION SELECT UPTO3 DRINER ALCOHOL I DRUG SUSPECTED CONDITION u1:i •I*I IIIaIIejI1t

SELECTUPTO2 DISTRACTED STATUS TYPE VALUE STATUS TYPE RESULTsEEEttoUJ BY Q ALCOHOL MARIJUANA

I______ UI ( / OTHER DRUG / /. •, I /H.I

UNIT # NAME; LAST, FIRST, MIDDLE ATE OF BIRT,H AGE GENDER

o, , rt / I 7/2 I/i 9 s /

ADDRESS: STREET,CITY,STATE,ZIP CONTACT PHONE - INCLUDE AREA CODE

Y’7/ W/9IZ sr /?EM ?/‘ /733 6 2 2 / 3 7 7INJURIES INJURED EMS AGENCY (NAME) INJUREDTAKENTO: MEDICAL FACILITY IEAME,CITYI SAFETY EQUIPMENT SEATING PISIN AIR BAG USAGE EJECTION TRAPPED

,

TAKEN USED) DOTCoMNr

I 0, I /

DL STATE OPERATOR liCENSE NUMBER OFFENSE CHARGED LOCAL OFFENSE DESCRIPTION CITATION NUMBER

//, X 9CODE

DL CLASS ENDIRSEMENT RESTRICTIIN SELECT UPTD3 DRIVER ALCOHOL! DRUG SUSPECTED CONDITION hJi1JIPI*ijSELECTUPTO2 DISTRACTED STATUS TYPE VALUE STATUS TYPE I RESULT ;UTo

BY ALCOHOL MARIJUANA j

r .1 I ) &I I I ) I ) / fl 0TH ER DRUG / I•) )

IIPI 11* IIIl*1IIli JJ1 ‘J: i’1iliIEtl:1±t ii’ii. N1tlUIISEATING POSITION AIR BAG DL CLASS

INJURED TAI(EN BY

SAFETY EQUIPMENT

EJECTION DL ENDORSEMENT

TRAPPED

ALCOHOL TEST TYPE

1-FATAL 1-FRONT—LEFTSIDE 1-NOTDEPLDYED 1-CLASSA 1-ALCOHOLINTERLOCKDEVICE 1-NOTDISTRACTED 1-NONEGIVEN(MOTORCYCLE DRIVER)2- SUSPECTED SERIOUS INJURY 2- DEPLOYED FRONT 2- CLASS B 2- CDL INTRASTATE ONLY 2 - MANUALLY OPERATING AN 2-TEST REFUSED

2-FRONT-MIDDLE3- SUSPECTED MINOR INJURY 3- DEPLOYED SIDE 3- CLASS C 3- CORRECTIVE LENSES ELECTRONIC COMMUNICATION 3 -TEST GIVEN, CONTAMINATEDDEVICE (TEXTING,TYPING, SAMPLE! UNUSABLE3- FRONT— RIGHT SIDE 4- DEPLOYED ROTH FRONT) SIDE 4- REGULAR CLASS 4- FARM WAIVER DIALING)4- POSSIBLE INJURY

5-NO APPARENT INJURY 4- SECOND— LEFT SIDE (OHIO = 0) 4 -TEST GIVEN, RESULTS KNOWN5-NOTAPPLICABLE 5-EXCEPTCLASSABUS 3-TALKINGON HANDS-FREE(MOTORCYCLE PASSENGER) 5- M)C MOPED ONLY9- DEPLOYMENT UNKNOWN 6- EXCEPT CLASSA COMMUNICATION DEVICE 5 -TEST GIVEN, RESULTS5 -SECOND— MIDDLE 6- NO VALID OL & CLASS I BUS 4 -TALKING ON HAND-HELD

UNKNOWN

6- SECOND — RIGHT SIDE1- NOTTRANSPORTED 7- EXCEPITRACTOR-TRAILER COMMUNICATION DEVICE(TREATED AT SCENE 7 -THIRD — LEFT SIDE 8- INTERMEDIATE LICENSE 5- OTHER ACTIVITY WITH AN

1-NONE(MOTORCYCLE SIDE CAR)2- EMS 1- NOT EJECTED H - HAZMAT RESTRICTIONS ELECTRONIC DEYICE8-THIRD-MIDDLE 2-BLOOD3- POLICE 2- PARTIALLY EJECTED M - MOTORCYCLE 9- LEARNER’S PERMIT 6- PASSENGER9 -THIRD — RIGHT SIDE RESTRICTIONS 7- OTHER DISTRACTION - URINE9-OTHER) UNKNOWN 3 -TOTALLY EJECTED P - PASSENGER

10- SLEEPER SECTION 10- LIMITEDTU DAYLIGHT ONLY INSIDETHE VEHICLE 4- BREATH4- NOTAPPLICABLE N -TANKER

UFTRUCK CAB 11- LIMITEUTO EMPLOYMENT I - OTHER DISTRACTION OUTSIDE 5- OTHERH - MOTOR SCOOTER THE VEHICLE1-NONEUSEB 11-PASSENGERINOTHER 12-LIMITED—OTHER

ENCLOSED CARGOAREA R-THREE-WHEEL MOTORCYCLE 9-OTHERIONKNDWN2- SHOULDER BELT ONLY USED (NON-TRAILING UNIT, BUS, 1- NOTTRAPPED 5 - SCHOOL BUS 13- MECHANICAL DEVICES1- NONE

3- LAP BELT ONLY USED PICK-UP WITH CAP) 2- EXTRICATED DY (SPECIAL BRAKES, HANDI- DOUBLE &TRIPLETRAILERS CONTROLS, OR OTHER 2- BLOOD

4- SHOULDER & LAP BELT OSED 12- PASSENGER IN UNENCLOSED MECHANICAL MEANS0-TANKER) HAZMAT ADAPTIVE DEVICES) 1 -APPARENTLY NORIAL 3- URINECARGOAREA 3- FREED BY5- CHILD RESTRAINT SYSTEM — 14- MILITARY VEHICLES ONLY 2- PHYSICAL IMPAIRMENT 4- OTHERFORWARD FACING 13 -TRAILING UNIT NON-MECHANICAL MEANS

15- MOTOR VEHICLES WITHOUT 3 - EMOTIONAL (Es, DEPRESNOD,6- CHILD RESTRAINT SYSTEM - 04- RIDING IN VEHICLE EXTERIOR

AIR BRAKES ANDRY, DISTURBED)REAR FACING (NON-TRAILING UNIT)

16-OUTSIDE MIRROR 4- ILLNESS 1-AMPHETAMINES7 - BOOSTER SEAT 15- NON-MOTORIST17- PROSTHETIC AID 5- FELLASLEEP, FAINTED, 2- BARBITURATESB - HELMET USED 99- OTHER! UNKNOWN

FATIGUED, ETC.10- OTHER 3- BENZODIA2EPINES9-PROTECTIVE PADS USED 6- UNOERTHE INFLUENCE)ELBOW, KNEES, ETC.) OF MEDICATIONS) DRUGS CANNABINOIDS

10- REFLECTIVE CLOTHING /ALCOHOL 5- COCAINE

11- LIGHTING — PEDESTRIAN 9-OTHER) UNKNOWN 6- OPIATES! OPIOIDS/ BICYCLE ONLY 7- OTHER

99-OTHER/UNKNOWN 8- NEGATIVE RESULTS

CONDITION

DRUG TEST TYPE

DRUG TEST RESULT(S)

HSY8306 OHIM 1/19 [760-1500) PAGE , OF$

MOTORIST I NON-MOTORIST’LOCAL REPORT NUMBER

/ I 9 / 1 0UNIT A NAME; LAST, FIRST, MIDDLE ATE OF BIR H AGE GENDER

q, VA £!/ if/V A 1/101/221/! I [I I /ADDRESS; STREET, CITY, STATE, ZIP CONTACT PHONE - IACLUDE AREA CODE

7Y0 7?oJif,es i)is,’V/zz,’/ Z/ Ii5i223 ?II

INJURIES INJURED EMS AGENCY (NAME) INJUREDTAKENTS: MEDICAL FACILITY INAME,CITY) SAFETTEQUIPHENT SEATING POSITION AIR BAG USAGE EJECTION TRAPPEDTAKEN USED , r900T.CIMPUANTBY Li L_JMC HELMET

—._-‘_J I________________, I I I I I I I ,___________j I

DL STATE OPERATOR LICENSE NUMBER OFFENSE CHARGED LOCAL OFFENSE DESCRIPTION CITATION NUMBER

LZZ& /34/7 CE

________

cZOL CLASS ENDORSEMENT RESTRICTION SELECT UPTO3 DRIVER ALCOHOL! DRUG SUSPECTED CONDITION I 411 II i*1

SELECTUPTO2 DISTRACTED STATUS TYPE VALUE STATUS TYPE RESULT SECECSUPTOS

BY ALCOHOL MARIJUANA

/ I II I I Q I I I I I I I 9 I OTHER DRUG / I

UNIT # NAME; CAST, FIRST, MIDDLE DATE OF BIRTH AGE GENDER

‘ I I I I I I I I II II

ADDRESS; STREET, CITY, STATE,ZIP CONTACT PHONE - INCLUDE AREA CODE

I I I I I I

INJURIES INJURED EMS AGENCY (NAME) INJUREDTAKENTS: MEDICAL FACILITY INAME,CITYI SAFETY EQUIPMENT SEATING POSITION AIR BAG USAGE EJECTION TRAPPEDTAKEN USED DOT-COMPLIANTBY ‘—1MC HELMET

I II I_ II II

DL STATE OPERATOR LICENSE NUMBER OFFENSE CHARGED LOCAL OFFENSE DESCRIPTION CITATION NUMBERCODE

I__

OL CLASS ENDORSEMENT RESTRICTION SELECT UPTO3 DRIVER ALCOHOL! DRUG SUSPECTED CONDITION IIOIIII I*1 iJiIIIIj(*110iSELECT UPTO2 DISTRACTED STATUS TYPE VALUE STATUS TYPE RESULT SEI0005pT04

BY ALCOHOL EJ MARIJUANA

1 I I I OTHER DRUG •‘ I ‘I’ LI

UNIT # NAME; LAST, FIRST, MIDDLE DATE OF BIRTH AGE GENDER

, I I I I I I I II

ADDRESS; STREET, CITY, STATE, ZIP CONTACT PHONE - ISCLUDE AREA CODE

, I I I I I I I

INJURIES INJURED EMS AGENCY (NAME) INJUREDTAKENTO: MEDICAL FACILITY INAME,CITYI SAFETY EQUIPMENT SEATING POSITION AIR BAG USAGE EJECTION TRAPPEDTAKEN USED r1 DOT-COMPLIANTBY ‘—MC HELMET

I I I I I I_

OL STATE OPERATOR LICENSE NUMBER OFFENSE CHARGED LOCAL OFFENSE DESCRIPTION CITATION NUMBERCODE

I__ E;IIII1II1I*N

-DL CLASS ENDORSEMENTSELECT UP TO 2

IIIII I

RESTRICTION SELECT UPTD 3

I I I I

SEATING POSITSON

DRIVER ALCOHOL! DRUG SUSPECTEDDISTRACTEDBY ALCOHOL Q MARIJUANA

_______

El OTHER DRUG

1- FATAL

2- SUSPECTED SERIOUS INJURY

3-SUSPECTED MINOR INJURY

4-POSSIBLE INJURY

5- NOAPPARENT INJURY

CONDITION

DL CLASS

INJURED TAKEN BY

1-NOTDEPLOYEI

2-DEPLOYED FRONT

3- DEPLOYED SIDE

4-DEPLOYED BOTH FRONT!SIOE

5-NOTAPPLICAILE

9-DEPLOYMENT UNKNOWN

STATUS TYPE VALUE SIATUS TYPE RESULTSp,;,S,.rs;

I II 1.1 I I II II II II II Ii

1- NOTTRANSPIRTEO/TREATEOAT SCENE

2-EMS

3-POLICE

9-OTHER/UNKNOWN

1- C LASS A

2-CLASS B

3- CLASS C

4-REGULAR CLASS(0010 = Dl

5- MIC MOPED ON LV

6- NO VALID AL

SAFETY EQUIPMENT

EJECTION OL ENDORSEMENT

1-FRONT-LEFT SIDE(MOTORCYCLE DRIVER)

2-FRONT- MIDDLE

3- FRONT - RIGHT SIDE

4-SECOND—LEFT SIDE(MOTORCYCLE PASSENGER)

S-SECOND—MIDDLE

6- SECOND— RIGHT SIDE

7-THIRD - LEFT SIDE(MOTORCYCLE SIDE CAR)

I-THIRD - MIDDLE

9-THIRD—RIGHT SIDE

10- SLEEPER SECTIONOFTRUCK CAB

11-PASSENGER IN OTHERENCLOSED CARGOAREA(NUN-TRAILING UNIT, BUS,PICK-UP WITH CAP)

12- PASSENGER IN UNENCLOSEDCARGO AREA

13-TRAILING UNIT

14- RIDING ON VEHICLE EXTERIOR(NON-TRAILING UNIT)

15- NON-MOTORIST

99-OTHER)UNKNOWN

1-NUT EJECTED

2-PARTIALLY EJECTED

3-TOTALLY EJECTED

4- NOT APPLICABLE

1- NONE GIVEN

2-TEST REFUSED

3-TEST GIVEN, CONTAMINATEDSAMPLE / UNUSABLE

4-TEST GIVEN, RESULTS KNOWN

s-TEST GIVEN, RESULTSUNKNOWN

1- NOT DISTRACTED

2-MANUALLY OPERATING ANELECTRONIC COMMUNICATIONDEVICE )TEXTINGTYPING,DIALING)

3-TALKING ON AANDS-FREECOMMUNICATION DEVICE

4-TALKING UNHAND-HELDCOMMUNICATION DEVICE

5-OTHER ACTIVITY WITH ANELECTRONIC DEVICE

6-PASSENGER

7-OTHER DISTRACTIONIN SIDE THE VE HICLE

8-OTHER DISTRACTION OUTSIDETHE VEHICLE

9-OTHER) UNKNOWNTRAPPED

H-HAZMAT

U - MOTORCYCLE

P - PASSENGER

N-TANKER

U-MOTOR SCOOTER

R-THREE-WHEEL MOTORCYCLE

S-SCHOOL BUS

T- DHUBLE&TRIPLETRAILERS

-TANKER! OAZMAT

ALCOHOL TEST TYPE

1- ALCOHOL INTERLOCK DEVICE

2- CDL INTRASTATE ONLY

3-CORRECTIVE LENSES

4-FARM WAIVER

S-EXCEPTCLASSADUS

6-EXCEPTCLASSA&CLASSIBUS

7- EXCEPTTRACTOR-TRAILER

8-INTERMEDIATE LICENSERESTRICTIONS

9- LEARNER’S PERMITRESTRICTIONS

10- LIMITEDTO DAYLIGHT ONLY

II- LIMITEDTO EMPLOYMENT

12-LIMITED-OTHER

13- MECHANICAL DEVICES(SPECIAL BRAKES, HANDCONTROLS, OR OTHERADAPTIVE DEVICES)

14- MILITARY VEHICLES ONLY

15- MOTOR VEHICLES WITHOUTAIR BRAKES

16-OUTSIDE MIRROR

17- PROSTHETIC AID

10-OTHER

1-NOTTRAPPED

2-EXTRICATED BYMECHANICAL MEANS

3- FREED IVNON-MECHANICAL MEANS

1-NONE USED

2-SHOULDER BELT ONLY USED

3-LAP BELT ONLY USED

4-SHOULDER & LAP BELT USED

5-CHILD RESTRAINT SYSTEM —

FORWARD FACING

6- CHILD RESTRAINT SYSTEM —

REAR FACING

7-BOOSTER SEAT

B - HELMET USED

9-PROTECTIVE PADS USED(ELBOW, KNEES, ETC.(

10- REFLECTIVE CLOTHING

11-LIGHTING — PEDESTRIANBICYCLE ONLY

99-OTHER / UNKNOWN

1-NONE

2-BLOOD

3-URINE

4-BREATH

5- 0TH ER

CONDITION1-NONE

2-BLOOD

3-URINE

4-OTHER

DRUG TEST RESULT(S)

1 -APPARENTLY NORMAL

2- PHYSICAL IMPAIRUENT

3 - EMOTIONAL lEG DEPRESSED,ANGRY D)STLREED)

4-ILLNESS 1-AMPHETAMINES

5- FELLASLEEP, FAINTED, 2-BAROITURATESFATIGUED, ETC.

3- BENZODIAZEPINES6- ONDERTHE INFLUENCE

OF MEDICATIONS! DRUGS 4- CANNA8INOIDS

/ALCOHOC S-COCAINE

9- OTHER) UNKNOWN 6-OPIATES) UPIUIDS

7- 0TH ER

8-NEGATIVE RESULTS

HSY8306 OH1M 1/19 [760-15001 PAGE 1OF?

LOCAL REPORT NUMBER

LI) 1 /

OCCUPANT I WITNESS ADDENDUM

.. . J

UNIT # NAME: LAST, FIRST, MIDDLE DATE OF BIRTH AGE GENDER

/ /1/I/z/g ?iiY LADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CODE

3ity/ /FIf,%’,esi c; k’EAYT ),yr/%/2gc I33I0I3/

INJURIES INJURED I EMS AGENCY (NAME) I IN]UREDTAKENTO: MEDICAL FACILITY (NAME, CITY) I SAFETY EQUIPMENT SEATING PISITIIN AIR BAG USAGE (EJECTION TRAPPED— TAKEN I I I USEI DOT-COMPLIANT I

BY I I I) I I I 101 ‘7 U MC HELMET 3 i 0

UNIT # NAME: LAST, FIRST, MIDDLE DATE OF BIRTH AGE GENDER

‘ I I I ‘I II

ADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CODE

) I I)

INJURIES INJURED I EMSAGENCY (NAME) I INJUREDTAKENTO: MEDICAL FACILITY (NAME, CITY) I SAFETY EQUIPMENT ‘SEATING POSITIIN AIR BAG USAGE EJECIIIN TRAPPEDTAKEN I I I USED t9 DOT-COMPLIANT’

BY I I I LJMC HELMET I) I I I I I III L I__I

UNIT # NAME: LAST, FIRST, MIDDLE DATE OF BIRTH AGE GENDER

) I I I I I I I II I II

ADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CODE

I I I I

INJURIES INJURED EMS AGENCY (NAME) I INJUREDTAKENTO: MEDICAL FACILITY (NAME, CITY) SAFETY EQUIPMENT SEATING POSITION AIR BAG USAGE I EJECTIIN TRAPPEDTAKEN I I USEI —‘ DOT-COMPLIANT IBY I L_JMCHELMET

I I I I I I II III___.____._..__._]I

UNIT # NAME: LAST, FIRST, MIDDLE DATE OF BIRTH AGE GENDER

I I I II II

ADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CODE

I I I

INJURIES INJURED EMS AGENCY (NAME) I INIUREDTAKEN TO: MEDICAL FACILITY (NAME, CITY) I SAFETY EQUIPMENT ‘SEATING PISIUON I AIR BAG USAGE I EJECTION TRAPPEDTAKEN I I USED .— DOT-COMPLIANT’ ) i IBY I ) U MC HELMET I I____________________ I________________I I I I I I) I ‘

rSPECTED

SERIOUS INJURYVEHICLE OCCUPANT (MOTORCYCLE DRIVER)

2- DEPLOYED FRONT

II II1.

1 FATAL 1- NONE USED- 1- FRONT—LEFTSIDE 1- NOTDEPLOYED

3- SUSPECTED MINOR INJURY2- SHOULDER BELT ONLY USED 2- FRONT—MIDDLE

3- DEPLOYED SIDE3- FRONT — RIGHT SIDE4- POSSIBLE INJURY

3- LAP BELT ONLY USED4- SECOND — LEFT SIDE 4- DEPLOYED BOTH

5- NOAPPARENT INJURY4- SHOULDER& LAP BELT USED (MOTORCYCLE PASSENGER) FRONT/SIDE

5- CHILD RESTRAINTSYSTEM— 5- SECOND—MIDDLE 5- NOTAPPLICABLEFORWARD FACING 6- SECOND — RIGHT SIDE 9- DEPLOYMENT UNKNOWN

1- NOTTRANSPORTED 6- CHILD RESTRAINT SYSTEM — 7- THIRD - LEFT SIDE

/TREATED AT SCENE REAR FACING (MOTORCYCLE SIDE CAR)

8- THIRD — MIDDLE2-EMS 7-BOOSTERSEAT 1-NOTEJECTED9- THIRD — RIGHT SIDE

3- POLICE 8- HELMET USED 2- PARTIALLY EJECTED10- SLEEPER SECTION OFTRUCK CAB9- OTHER / UNI<NOWN 9- PROTECTIVE PADS USED 11- PASSENGER IN OTHER ENCLOSED 3- TOTALLY EJECTED

(ELBOW, KNEES, ETC.) CARGO AREA (NON-TRAILING UNIT, NOTAPPLICABLE10- REFLECTIVE CLOTHING BUS, PICK-UP WITH CAP)

12- PASSENGER IN UNENCLOSED11- LIGHTING — PEDESTRIAN CARGO AREA

/BICYCLE ONLY 1- NOTTRAPPED13- TRAILING UNIT

99-OTHER/UNKNOWN 2- EXTRICATED BY MECHANICAL14- RIDING ON VEHICLE EXTERIOR MEANS

(NON-TRAILING UNIT)

15- NON-MOTORIST 3- FREED BY NON-MECHANICALMEANS

99- OTHER/UNKNOWN

SAFETY EQUIPMENT USED

INJURED TAKEN BY

EJECTION

TRAPPED

NAME: LAST, FIRST, MIDDLE DATE OF BIRTH AGE GENDER

,CO, B,Q8A’// 5/Y/7 i2/I / 9:3‘j

ADDRESS: STREET, CITY, STATE, ZIP CONTA PHONE - INCLUDE AREA CODE

237 Y / e 1/EZ y z /V C/IEs,erd/1j /% 2/16 2C 5253 IjJ: 7 0 3148Z1NAME: LAST, FIRST, MIDOLE FATE OF BIRTH AGE GENDER

//PZE /zfA A i/1%iJ3:O//:%iiLii/11ADDRESS: STREET, CITY, STATE, ZIP CONTACI PHONE - IN LUDE AREA CODE

// ,qz/yyy’ A/qô,e 2/J V4’zc /Z7 i 3:3 g, / 3 ,c 33,NAME: LAST, FIRST, MIDDLE DATE OF BIRTH AGE GENDER

/,172’%/ ‘,k’/4 S17Z IOi2L/2 7//II7l I 2: / i I

ADDRESS: STREET, CITY, STATE, ZIP CONTAC PHONE - IN LOSE AREA CODE

/‘%2 //27/ /)/ /<‘E/’7 D// %‘%‘2 V’ ZL5OI /7/I

HSY 8355 CHIP 1/19 [760-1 5001 PAGE OF