CRASH DATE, TIME, SEVERITY, AND LOCATION Town Name. I-95 NB Exit Ramp 16 at East Main St. CRASH FACTORS AND CONDITIONS

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1 Page of 9 Number of Motor Vehicles: Automobiles, Motorcycles, etc. Number of Non-Motorists: Pedestrians, Bicyclists, etc. 2 0 Crash Summary (Front) Date of Crash (YYYYMMDD) Latitude Longitude TRAFFICWAY OWNERSHIP. Public Road. Private Road TRAFFICWAY CLASS. Trafficway, On Road. Trafficway, Not on Road. Non-Trafficway 04. Parking Lot LIGHT CONDITIONS. Daylight. Dawn. Dusk 04. Dark- Lighted 05. Dark- Not Lighted 06. Dark Unknown Lighting Time ( ) 8 6 CRASH DATE, TIME, SEVERITY, AND LOCATION Town Name Town # Norwalk Crash occurred on (street name or route #) at its intersection with (street name or route #) I-95 NB Exit Ramp 6 at East Main St. If not at an intersection: WEATHER CONDITIONS (choose up to 2). Clear. Cloudy. Fog, Smog, Smoke 04. Rain 05. Sleet or Hail 06. Freezing Rain/Drizzle 07. Snow 08. Blowing Snow 09. Severe Crosswinds 0. Blowing Sand, Soil, Dirt TRAFFICWAY SURFACE CONDITIONS. Dry. Wet. Snow 04. Slush 05. Ice/Frost 06. Moving Water 07. Sand 08. Mud, Dirt, Gravel 09. Oil 0. Standing Water WORK ZONE. No. Yes 04 distance TYPE OF INTERSECTION. Not an Intersection. Four-Way Intersection. T-Intersection 04. Y-Intersection 05. L-Intersection 06. Traffic Circle 07. Roundabout 08. Five-Point, or More Feet Tenths of Mile N, S, E, W CRASH FACTORS AND CONDITIONS LOCATION OF FIRST HARMFUL EVENT FIRST HARMFUL EVENT. On Roadway. Shoulder Non-Collision:. Median. Overturn/Rollover 04. Roadside. Fire / Explosion 05. Gore. Immersion, Full or Partial 06. Separator 04. Jackknife 05. Cargo/Equipment Loss or Shift 07. In Parking Lane or Zone 06. Fell/Jumped from Vehicle 08. Off-Roadway Location Unknown 07. Thrown or Falling Object 09. Outside Right-of-Way (trafficway) 08. Other Non-Collision CRASH-SPECIFIC LOCATION. Non-Junction. Intersection. Intersection-Related 04. Entrance / Exit Ramp 05. Entrance / Exit Ramp-Related 06. Railway Grade Crossing 07. Crossover-Related 08. Driveway Access 09. Driveway Access-Related 0. Shared-Use Path or Trail. Through Roadway 2. Acceleration / Deceleration Lane 3. On A Bridge 4. HOV Lane 5. Service or Rest Area 6. Weigh Station 7. Other Location Not Listed Above Within an Interchange Area (median, shoulder and roadside) SCHOOL BUS RELATED. No. Yes, a school bus was directly involved. Yes, a school bus was indirectly involved LOCATION. Before the First Work Zone Warning Sign. Advance Warning Area. Transition Area 04. Activity Area 05. Termination Area of Crash Severity Fatal Injury PDO name of nearest intersecting road, town line, or mile marker Collision with Person, Vehicle, or Non-Fixed Object: 09. Pedestrian 0. Pedal cycle/pedal-cyclist. Other Non-motorist 2. Railway Vehicle (train, engine) 40. Deer 3. Animal Other Than Deer (live) 4. Motor Vehicle in Operation 5. Parked Motor Vehicle 6. Struck by Falling, Shifting Cargo or Anything Set in Motion by Motor Vehicle 7. Work Zone/Maintenance Equipment 8. Other Non-Fixed Object Collision With Fixed Object: 9. Impact Attenuator/Crash Cushion 20. Bridge Overhead Structure 2. Bridge Pier or Support 22. Bridge Rail 23. Cable Barrier 24. Culvert 25. Curb 26. Ditch 27. Embankment 28. Guardrail Face 29. Guardrail End 30. Concrete Traffic Barrier 3. Other Traffic Barrier 32. Tree (standing) 33. Utility Pole/Light Support 34. Traffic Sign Support 35. Traffic Signal Support 36. Fence 37. Mailbox 38. Other Post, Pole or Support 39. Other Fixed Object (wall, building, tunnel, etc.) WORK ZONE CRASH INFORMATION TYPE. Lane Closure. Lane Shift / Crossover. Work on Shoulder or Median 04. Intermittent or Moving Work MANNER OF IMPACT (Applies to: multi-vehicle crashes) 4. Front to Rear. Front to Front. Angle 04. Sideswipe, Same Direction 05. Sideswipe, Opposite Direction 06. Rear to Side 07. Rear to Rear WORKERS PRESENT. No. Yes CONTRIBUTING CIRCUMSTANCES, ENVIRONMENTAL (choose up to 3). Weather Conditions. Visual Obstruction(s). Glare 04. Animal(s) in Roadway CONTRIBUTING CIRCUMSTANCES, ROAD (choose up to 3). Backup Due to Prior Crash. Backup Due to Prior Non-recurring Incident. Backup Due to Regular Congestion 04. Toll Booth/Plaza Related 05. Road Surface Condition (wet, icy, snow, slush, etc.) 06. Debris 07. Ruts, Holes, Bumps 08. Work Zone (construction/ maintenance/utility) 09. Worn, Travel-Polished Surface 0. Obstruction in Roadway. Traffic Control Device Inoperative, Missing, or Obscured 2. Shoulder (none, low, soft, high) 3. Non-Highway Work Complete all for crashes occurring in a Work Zone ENFORCEMENT PRESENT. No. Yes

2 Page 2 of 9 Crash Summary (Back) DIAGRAM Vehicles were moved prior to police arrival NARRATIVE Officers Narrative: Describe any unusual circumstances associated with the crash, including officer's observations. Refer to each by motor vehicle number and/or non-motorist number Upon arrival, Vehicle # was parked in the right shoulder of I-95 southbound. Vehicle #2 was not present. Traffic was moderate, the road surface was wet, and the weather was rain, with overcast conditions. I-95, in the area of the accident, consists of three southbound travel lanes, with a broad median bordered by a jersey barrier and a shoulder bordered by a metal beam guiderail. Vehicle # was stopped at a red light at the bottom of the exit ramp. Operator #2 was traveling on the exit ramp and failed to stop in time and struck the rear of Vehicle #. Operator #2 then evaded the scene. Operator # provided a sworn written statement, in which she stated in summary; I was stopped at the red light off exit 6, and I was struck on the left side of my car. I did not have a chance to retrieve a license plate number, and only saw a black SUV pass by me after the accident, which turned left and went through a red light. (See Attached Statement) Operator # denied any injuries. Vehicle # sustained minor damage, which consisted of scrapes to the paint on the rear bumper. (See two attached photos). Photo # is a photo of the rear end of Vehicle #, depicting an overall view of the damage. Photo #2 is a photo of the left corner of the rear bumper of Vehicle # depicting a close up view of the damage. My investigation revealed Vehicle # was stopped at a red light at the bottom of Exit Ramp #6. Vehicle #2 was traveling directly behind Vehicle # on the exit ramp. Operator #2 failed to stop in time and struck the left corner of the rear bumper of Vehicle #. Operator #2 then made a left turn onto East Main St and evaded the scene. Due to the lack of any identifiers for Vehicle #2, this case will be closed. No enforcement action has been taken. Should any information develop, this case will be re-opened. Related Incident Number CTDOT-2 Case Status O - Open C - Closed C Officer Signature: Michael Rollo Officer First Name Michael This report is a revision to a previously submitted report Officer Last Name Rollo Supervisor:Henry Bennett Badge Number 25 Police Agency Code Date & Time : Date & Time :

3 Page 3 of 9 Motor Vehicle ID: Number of occupants in Vehicle : (including the driver) VIN: V Make: Toyota Model: Camry Color: Red Year: Road on which vehicle was traveling: Exit Ramp 6- I-95 SEQUENCE OF EVENTS (choose up to four, in chronological order) Non-Collision. Overturn/Rollover. Fire / Explosion. Immersion, Full or Partial 04. Jackknife 05. Cargo/Equipment Loss or Shift 06. Equipment Failure (blown tire, brake failure, etc) 07. Separation of Units 08. Ran Off Roadway Right 09. Ran Off Roadway Left 0. Cross Median. Cross Center Line 2. Downhill Runaway 3. Fell/Jumped From Motor Vehicle 4. Reentering Roadway 5. Thrown or Falling Object 6. Other Non-Collision Collision With Person, Motor Vehicle, or Non-Fixed Object 7. Pedestrian 8. Pedal Cycle/Pedal-cyclist 9. Other Non-motorist 20. Railway Vehicle (train, engine) 2. Animal (live) 22. Motor Vehicle In Motion 23. Parked Motor Vehicle 24. Struck By Falling, Shifting Cargo or Anything Set In Motion By Motor Vehicle 25. Work Zone/Maintenance Equipment 26. Other Non-Fixed Object Collision With Fixed Object 27. Impact Attenuator/Crash Cushion 28. Bridge Overhead Structure 29. Bridge Pier or Support 30. Bridge Rail 3. Cable Barrier 32. Culvert 33. Curb 34. Ditch 35. Embankment 36. Guardrail Face 37. Guardrail End 38. Concrete Traffic Barrier 39. Other Traffic Barrier 40. Tree (standing) 4. Utility Pole 42. Traffic Sign Support 43. Traffic Signal Support 44. Other Post, Pole, or Support 45. Fence 46. Mailbox st 2 nd 3 rd 4 th 22 Most Harmful Event Other Fixed Object (wall, building, tunnel, etc.) 48. Light Support MOTOR VEHICLE ACTION. Straight Ahead. Negotiating a Curve 3. Backing 04. Changing Lanes 05. Overtaking/Passing Motor Vehicle 06. Turning Right 07. Turning Left 08. Making U-Turn 09. Leaving Traffic Lane 0. Entering Traffic Lane. Slowing 2. Parked 3. Stopped in Traffic 4. Overtaking/Passing Cyclist 5. Wrong Way or Wrong Side 6. Traveling in Bike Lane CONTRIBUTING CIRCUMSTANCES MOTOR VEHICLE (choose up to 2). Brakes. Exhaust System. Body, Doors 04. Steering 05. Power Train 06. Suspension 07. Tires 08. Wheels 09. Lights (head, signal, tail) 0. Windows/Windshield. Mirrors 2. Wipers 3. Truck Coupling / Trailer Hitch / Safety Chains TOWED TO MOTOR VEHICLE INFORMATION 00 POSTED/STATUTORY SPEED LIMIT (record the posted/statutory value as miles per hour). Not Posted 0, 5, 20, 25, 30, 35, 40, 45 50, 55, 60, 65, 70, 75, 80, 85 Motor Vehicle Information (Front) Complete One Sheet Per Motor Vehicle VIN missing or removed Driver Evaded Responsibility Direction of Travel N, S, E, W MOTOR VEHICLE CRASH INFORMATION TOWED. Towed Due to Disabling Damage. Towed, But Not Due to Disabling Damage. Not Towed Plate #: PB&J#2 Plate State: CT BODY TYPE. Passenger Car. (Sport) Utility Vehicle. Passenger Van 04. Cargo Van (<0,000 lbs GVWR) 05. Pickup 06. Motor Home 07. School Bus 08. Transit Bus 09. Motor Coach 0. Other Bus. Motorcycle 2. Moped 3. Low Speed Vehicle 4. Golf Cart 5. All Terrain Vehicle (ATV) 6. Snowmobile 7. Other Light Trucks (0,000 lbs GVWR or less) 8. Medium/Heavy Trucks (more than 0,000 lbs GVWR) INSURANCE INFORMATION Invalid Plate No Plate INSURANCE COMPANY INSURANCE POLICY NUMBER INSURANCE EXPIRATION DATE (yyyymmdd) Happy Cat's N MOTOR VEHICLE DAMAGE EXTENT OF DAMAGE. No Visible Damage. Minor Damage. Functional Damage 04. Disabling Damage Vehicle was not in roadway Unknown direction Use diagram above for values -2 See user guide for other vehicle diagrams. Initial Contact Point 3. Non-Collision 4. Top 5. Undercarriage 6. Cargo loss Damaged Areas (choose up to 3) 4. Top 5. Undercarriage 7. All Areas Total lanes in roadway: 2 Bike lanes/sharrows present MOTOR VEHICLE TYPE. Motor Vehicle in Operation. Parked Motor Vehicle. Working Vehicle/Equipment 04. Non-Collision Vehicle TRAFFICWAY DESCRIPTION. Two-Way, Not Divided. Two-Way, Not Divided w/ 05 a Continuous Left Turn Lane. Two-Way, Divided, Unprotected (Painted >4 Feet) Median 04. Two-Way, Divided, Positive Median Barrier 05. One-Way Trafficway ROADWAY GRADE. Level. Uphill. Hill Crest 04. Downhill 05. Sag (bottom) ROADWAY ALIGNMENT. Straight. Curve Left. Curve Right TRAFFIC CONTROL DEVICE TYPE. No Control Device. Person (flagger, law enforcement, crossing guard, etc.). Traffic Control Signal 04. Flashing Traffic Control Signal 05. School Zone Sign/Device 06. Stop Sign 07. Yield Sign 08. Warning Sign 09. Railway Crossing Device 0. Marked Uncontrolled Crosswalk. Pedestrian Button 2. Bicycle Detection TRAFFIC CONTROL DEVICE FUNCTIONAL?. No. Yes. Missing

4 Page 4 of 9 Vehicle Owner Name (Last, First, Middle, Suffix) Motor Vehicle Information (Back) Complete One Sheet Per Motor Vehicle MOTOR VEHICLE OWNERSHIP INFORMATION Information same as driver Street Address or Post Office Box City State/Prov Country Postal Code United States Address (optional) Phone (optional) SPECIAL VEHICLE FUNCTION. No Special Function. Taxi. Vehicle Used as School Bus 04. Vehicle Used as Other Bus 05. Military 06. Police 07. Ambulance 08. Fire Truck 09. Non-Transport Emergency 0. Incident Response Services Vehicle MOTOR VEHICLE INFORMATION SPECIAL VEHICLES EMERGENCY VEHICLE. Non-Emergency Situation, Not Transporting Patient. Non-Emergency Transport of Passenger. Emergency Operation, Emergency Warning Equipment Not in Use 04. Emergency Operation, Emergency Warning Equipment in Use BUS USE. Not a Bus. School. Transit/Commuter 04. Intercity 05. Charter/Tour 06. Shuttle Complete if public or private property other than vehicles were damaged in the crash NATURE AND EXTENT OF DAMAGE TO PROPERTY N/A PROPERTY DAMAGED NAME OF OWNER OF PROPERTY N/A NATURE AND EXTENT OF DAMAGE TO PROPERTY 2 NAME OF OWNER OF PROPERTY 2 NATURE AND EXTENT OF DAMAGE TO PROPERTY 3 NAME OF OWNER OF PROPERTY 3

5 Page 5 of 9 Motor Vehicle ID: Number of occupants in Vehicle : (including the driver) VIN: Make: Model: Color: Year: Road on which vehicle was traveling: Exit 6 Ramp -I-95 SEQUENCE OF EVENTS (choose up to four, in chronological order) Non-Collision. Overturn/Rollover. Fire / Explosion. Immersion, Full or Partial 04. Jackknife 05. Cargo/Equipment Loss or Shift 06. Equipment Failure (blown tire, brake failure, etc) 07. Separation of Units 08. Ran Off Roadway Right 09. Ran Off Roadway Left 0. Cross Median. Cross Center Line 2. Downhill Runaway 3. Fell/Jumped From Motor Vehicle 4. Reentering Roadway 5. Thrown or Falling Object 6. Other Non-Collision Collision With Person, Motor Vehicle, or Non-Fixed Object 7. Pedestrian 8. Pedal Cycle/Pedal-cyclist 9. Other Non-motorist 20. Railway Vehicle (train, engine) 2. Animal (live) 22. Motor Vehicle In Motion 23. Parked Motor Vehicle 24. Struck By Falling, Shifting Cargo or Anything Set In Motion By Motor Vehicle 25. Work Zone/Maintenance Equipment 26. Other Non-Fixed Object Collision With Fixed Object 27. Impact Attenuator/Crash Cushion 28. Bridge Overhead Structure 29. Bridge Pier or Support 30. Bridge Rail 3. Cable Barrier 32. Culvert 33. Curb 34. Ditch 35. Embankment 36. Guardrail Face 37. Guardrail End 38. Concrete Traffic Barrier 39. Other Traffic Barrier 40. Tree (standing) 4. Utility Pole 42. Traffic Sign Support 43. Traffic Signal Support 44. Other Post, Pole, or Support 45. Fence 46. Mailbox st 2 nd 3 rd 4 th Most Harmful Event 47. Other Fixed Object (wall, building, tunnel, etc.) 48. Light Support 2 MOTOR VEHICLE ACTION. Straight Ahead. Negotiating a Curve. Backing 04. Changing Lanes 05. Overtaking/Passing Motor Vehicle 06. Turning Right 07. Turning Left 08. Making U-Turn 09. Leaving Traffic Lane 0. Entering Traffic Lane. Slowing 2. Parked 3. Stopped in Traffic 4. Overtaking/Passing Cyclist 5. Wrong Way or Wrong Side 6. Traveling in Bike Lane CONTRIBUTING CIRCUMSTANCES MOTOR VEHICLE (choose up to 2). Brakes. Exhaust System. Body, Doors 04. Steering 05. Power Train 06. Suspension 07. Tires 08. Wheels 09. Lights (head, signal, tail) 0. Windows/Windshield. Mirrors 2. Wipers 3. Truck Coupling / Trailer Hitch / Safety Chains TOWED TO MOTOR VEHICLE INFORMATION (ii) POSTED/STATUTORY SPEED LIMIT (record the posted/statutory value as miles per hour). Not Posted 0, 5, 20, 25, 30, 35, 40, 45 50, 55, 60, 65, 70, 75, 80, 85 Motor Vehicle Information (Front) Complete One Sheet Per Motor Vehicle VIN missing or removed Driver Evaded Responsibility Direction of Travel N, S, E, W MOTOR VEHICLE CRASH INFORMATION TOWED. Towed Due to Disabling Damage. Towed, But Not Due to Disabling Damage. Not Towed Plate State: CT BODY TYPE. Passenger Car. (Sport) Utility Vehicle. Passenger Van 04. Cargo Van (<0,000 lbs GVWR) 05. Pickup 06. Motor Home 07. School Bus 08. Transit Bus 09. Motor Coach 0. Other Bus. Motorcycle 2. Moped 3. Low Speed Vehicle 4. Golf Cart 5. All Terrain Vehicle (ATV) 6. Snowmobile 7. Other Light Trucks (0,000 lbs GVWR or less) 8. Medium/Heavy Trucks (more than 0,000 lbs GVWR) INSURANCE INFORMATION Invalid Plate No Plate INSURANCE COMPANY INSURANCE POLICY NUMBER INSURANCE EXPIRATION DATE (yyyymmdd) N MOTOR VEHICLE DAMAGE EXTENT OF DAMAGE. No Visible Damage. Minor Damage. Functional Damage 04. Disabling Damage Plate #: Vehicle was not in roadway Unknown direction Use diagram above for values -2 See user guide for other vehicle diagrams. Initial Contact Point 3. Non-Collision 4. Top 5. Undercarriage 6. Cargo loss Damaged Areas (choose up to 3) 4. Top 5. Undercarriage 7. All Areas Total lanes in roadway: 2 Bike lanes/sharrows present MOTOR VEHICLE TYPE. Motor Vehicle in Operation. Parked Motor Vehicle. Working Vehicle/Equipment 04. Non-Collision Vehicle TRAFFICWAY DESCRIPTION. Two-Way, Not Divided. Two-Way, Not Divided w/ 05 a Continuous Left Turn Lane. Two-Way, Divided, Unprotected (Painted >4 Feet) Median 04. Two-Way, Divided, Positive Median Barrier 05. One-Way Trafficway ROADWAY GRADE. Level. Uphill. Hill Crest 04. Downhill 05. Sag (bottom) ROADWAY ALIGNMENT. Straight. Curve Left. Curve Right TRAFFIC CONTROL DEVICE TYPE. No Control Device. Person (flagger, law enforcement, crossing guard, etc.). Traffic Control Signal 04. Flashing Traffic Control Signal 05. School Zone Sign/Device 06. Stop Sign 07. Yield Sign 08. Warning Sign 09. Railway Crossing Device 0. Marked Uncontrolled Crosswalk. Pedestrian Button 2. Bicycle Detection TRAFFIC CONTROL DEVICE FUNCTIONAL?. No. Yes. Missing

6 Page 6 of 9 Vehicle Owner Name (Last, First, Middle, Suffix) Motor Vehicle Information (Back) Complete One Sheet Per Motor Vehicle MOTOR VEHICLE OWNERSHIP INFORMATION Information same as driver Street Address or Post Office Box City State/Prov Country Postal Code United States Address (optional) Phone (optional) SPECIAL VEHICLE FUNCTION. No Special Function. Taxi. Vehicle Used as School Bus 04. Vehicle Used as Other Bus 05. Military 06. Police 07. Ambulance 08. Fire Truck 09. Non-Transport Emergency 0. Incident Response Services Vehicle MOTOR VEHICLE INFORMATION SPECIAL VEHICLES EMERGENCY VEHICLE. Non-Emergency Situation, Not Transporting Patient. Non-Emergency Transport of Passenger. Emergency Operation, Emergency Warning Equipment Not in Use 04. Emergency Operation, Emergency Warning Equipment in Use BUS USE. Not a Bus. School. Transit/Commuter 04. Intercity 05. Charter/Tour 06. Shuttle Complete if public or private property other than vehicles were damaged in the crash NATURE AND EXTENT OF DAMAGE TO PROPERTY N/A PROPERTY DAMAGED NAME OF OWNER OF PROPERTY N/A NATURE AND EXTENT OF DAMAGE TO PROPERTY 2 NAME OF OWNER OF PROPERTY 2 NATURE AND EXTENT OF DAMAGE TO PROPERTY 3 NAME OF OWNER OF PROPERTY 3

7 Page 7 of 9 Name (Last, First, Middle, Suffix): ACTION BY OFFICER Taken. Verbal Warning. Written Warning. Infraction 04. Arrest/Summons 00 Motor Vehicle ID: Person ID: Street Address Happy Place or PO Box: City: Newington LICENSE INFO LICENSE NUMBER STATE CT Doe, Priscilla, Lou DRIVER LICENSE JURISDICTION. Not Licensed. State. Tribal Nation 04. U.S. Government 05. Canadian Province 06. Mexican State 07. International License (other than Mexico and Canada) 08. Valid License (other country) LICENSE CLASS. Class A. Class B. Class C 04. Class D 05. Class M 04 COMMERCIAL LICENSE. No. Yes ENDORSEMENTS A - Activity Vehicles F - Taxi, Livery, Motor Coach H - Hazardous Materials M - Motorcycles N - Tank Vehicles P - Passenger Q - Fire Fighting Vehicles S - School Bus T - Double/Triple Trailers V - Student Transportation X - Combination of Tank Vehicle and Hazardous Materials EJECTION. Not Ejected. Ejected, Partially. Ejected, Totally AIRBAG. Not Deployed. Deployed-Front. Deployed-Side 04. Deployed-Curtain 05. Deployed-Other 06. Deployed-Combination SPEED RELATED. No. Racing. Exceeded Speed Limit 04. Too Fast for Conditions State or Prov: RESTRAINT SYSTEM Used-Motor Vehicle Occupant. Shoulder and Lap Belt Used. Shoulder Belt Only Used. Lap Belt Only Used 04. Restraint Used Type Unknown Motor Vehicle Driver Information Complete One Sheet Per Driver HELMET USE. No Helmet. DOT-Compliant Motorcycle Helmet. Helmet, Other Than DOT-Compliant Motorcycle Helmet 04. Helmet, Unknown If DOT-Compliant INJURY STATUS K. Fatal Injury A. Suspected Serious Injury B. Suspected Minor Injury C. Possible Injury O. No Apparent Injury O CT ENFORCEMENT ACTIONS TAKEN VIOLATION STATUTES Postal 06 Code: GENDER. Male. Female. Unknown Phone/ (optional): DRIVER INFORMATION SEATING POSITION FIRST DIGIT _. Front Row SECOND DIGIT _. Left Seat (usually the motor vehicle or motorcycle driver except for postal vehicles and some foreign vehicles) _2. Middle Seat _3. Right Seat _8. Other Seat INJURY AND EMS INFORMATION TRANSPORTED TO FIRST EMS COMPANY NAME MEDICAL FACILITY BY. Not Transported EMS RUN NUMBER. EMS Air. EMS Ground INTENDED RECEIVING FACILITY 04. Law Enforcement DATE OF BIRTH (YYYYMMDD) Date of Birth is unknown DRIVER ACTIONS (choose up to 4). No Contributing Action. Ran Off Roadway. Failed to Yield Right-of-Way 04. Ran Red Light 05. Ran Stop Sign 06. Disregarded Other Traffic Sign 07. Disregarded Other Road Markings 08. Improper Turn 09. Improper Backing 0. Improper Passing. Wrong Side or Wrong Way 2. Followed Too Closely 3. Failed to Keep in Proper Lane 4. Operated Vehicle in Reckless Aggressive Manner 5. Operated Motor Vehicle in Inattentive, Careless, Negligent, or Erratic Manner 6. Swerved or Avoided Due to Wind, Motor Vehicle, Object, Non-Motorist in Roadway, etc. 7. Over-Correcting/Over-Steering 8. Overtaking Cyclist Contributing Action DRIVER DISTRACTED BY. Not Distracted. Manually Operating an Electronic Communication Device (Texting, etc). Talking on Hands-Free Electronic Device 04. Talking on Hand-Held Electronic Device 05. Other Activity, Electronic Device 06. Passenger 07. Other Inside the Vehicle (eating, hygiene, etc.) 08. Outside the Vehicle CONDITION AT TIME OF CRASH (choose up to 2). Apparently Normal. Physically Impaired. Emotional (depressed, angry, etc.) 04. Ill (sick), Fainted 05. Asleep or Fatigued 06. Under the Influence (Medications/Drugs/Alcohol). Unknown DRUG/ALCOHOL INFORMATION ALCOHOL TEST STATUS TYPE OF ALCOHOL TEST. Test Not Given. Blood. Test Refused. Urine. Test Given. Breath. Unknown if Tested TYPE OF DRUG TEST DRUG TEST STATUS. Test Not Given. Test Refused. Test Given. Unknown if Tested. Blood. Urine

8 Page 8 of 9 Name (Last, First, Middle, Suffix): unknown Street Address or PO Box: City: LICENSE INFO LICENSE NUMBER STATE CT ACTION BY OFFICER Taken. Verbal Warning. Written Warning. Infraction 04. Arrest/Summons 00 Motor Vehicle ID: DRIVER LICENSE JURISDICTION. Not Licensed. State. Tribal Nation 04. U.S. Government 05. Canadian Province 06. Mexican State 07. International License (other than Mexico and Canada) 08. Valid License (other country) LICENSE CLASS. Class A. Class B. Class C 04. Class D 05. Class M COMMERCIAL LICENSE. No. Yes ENDORSEMENTS A - Activity Vehicles F - Taxi, Livery, Motor Coach H - Hazardous Materials M - Motorcycles N - Tank Vehicles P - Passenger Q - Fire Fighting Vehicles S - School Bus T - Double/Triple Trailers V - Student Transportation X - Combination of Tank Vehicle and Hazardous Materials Person ID: 2 2 EJECTION. Not Ejected. Ejected, Partially. Ejected, Totally AIRBAG. Not Deployed. Deployed-Front. Deployed-Side 04. Deployed-Curtain 05. Deployed-Other 06. Deployed-Combination SPEED RELATED. No. Racing. Exceeded Speed Limit 04. Too Fast for Conditions State or Prov: RESTRAINT SYSTEM Used-Motor Vehicle Occupant. Shoulder and Lap Belt Used. Shoulder Belt Only Used. Lap Belt Only Used 04. Restraint Used Type Unknown Motor Vehicle Driver Information Complete One Sheet Per Driver HELMET USE. No Helmet. DOT-Compliant Motorcycle Helmet. Helmet, Other Than DOT-Compliant Motorcycle Helmet 04. Helmet, Unknown If DOT-Compliant INJURY STATUS K. Fatal Injury A. Suspected Serious Injury B. Suspected Minor Injury C. Possible Injury O. No Apparent Injury O ENFORCEMENT ACTIONS TAKEN VIOLATION STATUTES Postal Code: GENDER. Male. Female. Unknown Phone/ (optional): DRIVER INFORMATION (ii) SEATING POSITION FIRST DIGIT _. Front Row SECOND DIGIT _. Left Seat (usually the motor vehicle or motorcycle driver except for postal vehicles and some foreign vehicles) _2. Middle Seat _3. Right Seat _8. Other Seat INJURY AND EMS INFORMATION TRANSPORTED TO FIRST EMS COMPANY NAME MEDICAL FACILITY BY. Not Transported EMS RUN NUMBER. EMS Air. EMS Ground INTENDED RECEIVING FACILITY 04. Law Enforcement DATE OF BIRTH (YYYYMMDD) Date of Birth is unknown DRIVER ACTIONS (choose up to 4). No Contributing Action. Ran Off Roadway. Failed to Yield Right-of-Way 04. Ran Red Light 05. Ran Stop Sign 06. Disregarded Other Traffic Sign 07. Disregarded Other Road Markings 08. Improper Turn 09. Improper Backing 0. Improper Passing. Wrong Side or Wrong Way 2. Followed Too Closely 3. Failed to Keep in Proper Lane 4. Operated Vehicle in Reckless Aggressive Manner 5. Operated Motor Vehicle in Inattentive, Careless, Negligent, or Erratic Manner 6. Swerved or Avoided Due to Wind, Motor Vehicle, Object, Non-Motorist in Roadway, etc. 7. Over-Correcting/Over-Steering 8. Overtaking Cyclist Contributing Action DRIVER DISTRACTED BY. Not Distracted. Manually Operating an Electronic Communication Device (Texting, etc). Talking on Hands-Free Electronic Device 04. Talking on Hand-Held Electronic Device 05. Other Activity, Electronic Device 06. Passenger 07. Other Inside the Vehicle (eating, hygiene, etc.) 08. Outside the Vehicle CONDITION AT TIME OF CRASH (choose up to 2). Apparently Normal. Physically Impaired. Emotional (depressed, angry, etc.) 04. Ill (sick), Fainted 05. Asleep or Fatigued 06. Under the Influence (Medications/Drugs/Alcohol). Unknown DRUG/ALCOHOL INFORMATION ALCOHOL TEST STATUS TYPE OF ALCOHOL TEST. Test Not Given. Blood. Test Refused. Urine. Test Given. Breath. Unknown if Tested TYPE OF DRUG TEST DRUG TEST STATUS. Test Not Given. Test Refused. Test Given. Unknown if Tested. Blood. Urine

9 Page 9 of 9 Appendix A: Narrative Continued Complete this sheet if more space is needed for the narrative NARRATIVE CONTINUED (i)