FLORIDA TRAFFIC CRASH REPORT

Transcription

1 LONG FORM This Traffic Crash Report can be purchased online at: ORIDA TRAFFIC CRASH REPORT SHORT FORM (Shaded Areas) UPDATE MAIL TO: DEPARTMENT OF HIGHWAY SAFETY & MOTOR VEHICLES TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING TALLAHASSEE, 99-0 WAS DOT PROPERTY INVOLVED IN THIS CRASH? TOTAL # OF VEHICLE SECTION(S) TOTAL # OF PERSON SECTION(S) TOTAL # OF NARRATIVE SECTION(S) CRASH DATE //0 CRASH IDENTIFIERS COUNTY CODE 0 WITNESSES SANDRA Light Condition Daylight Dusk Dawn Dark-Lighted First Harmful Event First Harmful Event within Interchange No Yes Non-Junction Intersection Intersection-Related Driveway/Alley Access Related CITY CODE Work Zone Related NAME Dark-Not Lighted 6 Dark-Unknown Lighting Weather Condition Flog, Smog, Smoke Sleet/Hail/ Freezing Rain 6 Blowing Sand, Soil Dirt Clear Severe Crosswinds Cloudy Rain Non-Collision Overturn/Rollover Fire/Explosion Immersion Jackknife Cargo/Equipment Loss or Shift 6 Fell/Jumped From Motor Thrown or Falling Object 8 Ran int Water/Canal 9 Other Collision First Harmful Event Relation to No Yes TIME OF CRASH 8: AM COUNTY OF CRASH PINELLAS CRASH INFORMATION (CHECK IF PICTURES TAKEN) DATE OF REPORT //0 TIME ON SCENE TIME CLEARED SCENE CHECK IF 8:8 AM 9: AM COMPLETED ROADWAY INFORMATION (CHOOSE ONLY OF OPTIONS) Roadway Surface Condition Oil 6 Mud, Dirt, Gravel Sand 8 Water (standing/moving) Dry Wet Ice/Frost Collision Non-Fixed Object 0 Pedestrian 9 Impact Attenuator/Crash Pedalcycle Cusion Railway vehicle (train, 0 Bridge Overhead Structure engine) Bridge Pier or Support Animal Bridge Rail Motor in Culvert Transport Curb Parked Motor Ditch 6 Work Zone/Maintainance 6 Embankment Equipment Guardrail Face Struck By Falling, Shifting 8 Guardrail End Cargo 9 Cable Barrier 8 Other Non-Fixed Object Contributing Circumstances: Road Junction Railway Grade Crossing Entrance/Exit Ramp Crossover - Related None 6 Shared-Use of Path or Trail Acceleration/Dceleration Lane Work Zone (construction/ maintenance/utility 8 Through Roadway ) 6 Shoulders (none, low, soft, high) Rut, Holes, Bumps Crash in Work Zone Before the First Work Zone Warning Sign Advance Warning Area Transition Area Activity Area Termination Area Type of Work Zone Lane Closure Lane Shift/Crossover Work on Shoulder or Median Intermittent or Moving Work J TURNER 0 TH AVE REPORTING AGENCY CASE NUMBER SO-006 PLACE OR CITY OF CRASH BELLEAIR BLUFFS REASON (If Investigation NOT Complete) CRASH OCCURRED ON STREET, ROAD, HIGHWAY AT STREET ADDRESS # INDIAN ROCKS RD 0 AT FEET MILES N S E W Interstate U.S. State Road System Identifier County Local 6 Turnpike/Toll Forest Road 8 Private Roadway 9 Parking Lot AT/FROM INTERSECTION WITH STREET, ROAD,HIGHWAY WEST BAY DR Type of Shoulder Paved Unpaved Curb ADDRESS School Bus Related CITY & LARGO NAME ADDRESS CITY & No Yes, School Bus Directly Involved Yes, School Bus Indirectly Involved Collision with Fixed Object 0 Concrete Other Traffic Barrier Tree (standing) Utility Pole/Light Support Traffic Sign Support Traffic Signal Support 6 Ohter Post, Pole or Support Fence 8 Mailbox 9 Other Fixed Object (wall, building, tunnel, etc.) 9 Worn, Travel-Polished Surface 0 Raod Surface Condition (wet, icy, snow, slush, etc.) Obstruction in Roadway Debris Traffic Control Inoperative, Missing or Obscured Non-Highway Work HSMV CRASH REPORT NUMBER 8688 CHECK IF WITHIN CITY LIMITS AT LATITUDE Type of Intersection Not at Intersection Four-Way Intersection T-Intersection Y-Intersection Workers in Work Zone No Yes TIME REPORTED Front to Rear Front to Front Angle 8: AM Manner of Collision/Impact Sideswipe, same direction Sideswipe, Opposite Direction 6 Rear to Side Rear to Rear First Harmful Event Location On Roadway Off Roadway Shoulder Median 6 Gore Separator 8 In Parking Lane or Zone 9 Outside Right-of-way 0 Roadside Contributing Circumstances: Environment None Weather Conditions Physical Obstruction(s) Glare TIME DISPATCHED 8: AM Notified By: Motorist Law Enforcement AND LONGITUDE OR FROM MILEPOST # 0 Traffic Circle 6 Roundabout Five-Point, or More Animal(s) in Roadway Law Enforcement in Work Zone No Officer Present Law Enforcement Only Present NAME ADDRESS CITY & NON VEHICLE PROPERTY DAMAGE VEH. # PER # PROPERTY DAMAGE - OTHER THAN VEH. EST. AMT. OWNER'S NAME (CHECK IF BUSINESS) ADDRESS CITY & VEH. # PER # PROPERTY DAMAGE - OTHER THAN VEH. EST. AMT. OWNER'S NAME (CHECK IF BUSINESS) ADDRESS CITY & HSMV 9000 S

2 in Transport VEHICLE LICENSE NUMBER Parked Motor Working 86PA Hit and Run No Yes YEAR 00 INSURANCE COMPANY (DRIVER) INFINITY AUTO INSURANCE COMPANY MARTHA C BORRERO Trailer One: LICENSE NUMBER MAKE MITS NAME OF VEHICLE OWNER (CHECK IF BUSINESS) Check if Commercial MODEL ECLIPSE INSURANCE POLICY NUMBER CURRENT ADDRESS 66 TAM CT SO-006 REGISTRATION EXPIRES 0//06 REGISTRATION EXPIRES Check if Permanent STYLE DOOR SEDAN Check if Permanent COLOR VIN MAROON, BURGUNDY (PURPL 8688 AACGE0980 Towed due VEHICLE REMOVED BY to Damage: No Yes JOE'S TOWING CITY & WINTER SPRINGS DAMAGE: EST. AMOUNT Disabling Minor Functional None $, Rotation. Owner Request. Driver. Other, Explain in ZIP 08 VIN YEAR MAKE LENGTH AXLES Trailer Two: LICENSE NUMBER REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES VEHICLE TRAVELING HAZ. MAT. RELEASED No Yes MOTOR CARRIER NAME N S E W Off-Road Unknown HAZ. MAT. PLACARD No Yes NUMBER US DOT NUMBER ON STREET, ROAD, HIGHWAY WEST BAY DR CLASS Area of Initial Impact AT EST. SPEED POSTED SPEED Undercarriage 8 9 Overturn 9 0 Windshield 0 Trailer TOTAL LANES Most Damaged Area MOTOR CARRIER ADDRESS CITY PHONE NUMBER VIOLATIONS Body Type Passenger Car Passenger Van Pickup Motor Home 8 Bus Motorcycle Moped All Terrain (ATV) Most Harmful Event Sequence of Events st rd NAME OF VIOLATOR ANICETO ANICETO PENCA NAME OF VIOLATOR Low Speed 6 (Sport) Utility Cargo Van (0,000 lbs (,6 kg) or less) 8 Motor Coach 9 Other Light Trucks (0,000 lbs (,6 kg) or less) 0 Medium/Heavy Trucks (more than 0,000 lbs (,6 kg)) Farm Labor Interstate Carrier Intrastate Carrier Not in Commerce/Government Not in Commerce/Other Truck Non-Collision Overturn/Rollover Fire/Explosion Immersion Jackknife Cargo/Equipment Loss or Shift 6 Fell/Jumped From Motor Thrown or Falling Object 8 Ran into Water/Canal 9 Other Non-Collision [0-6 Sequence of Events only] 0 equipment Failure (blown tire, brake failure, etc.) Separation of Units Ran Off Roadway, Right Ran Off Roadway, Left Cross Median Cross Centerline 6 Downhill Runaway PENCA CHAVEZ CHAVEZ Trafficway Two-Way, Not Divided Two-Way, Not Divided, with a Continuous Left Turn Lane Two-Way, Divided, Unprotected (painted > feet) Median Two-Way, Divided, Positive Median Barrier One-Way Trafficway Comm/Non-Commercial TRAILER TRAILER nd th Roadway Grade Level Hillcrest Uphill Downhill Sag (bottom) Special Function of Motor Roadway Alignment Straight Curve Right Curve Left No Special Function Farm Police Taxi 8 Military Comm GVWR/GCWR STATUTE NUMBER.0() STATUTE NUMBER 6.9 Single Semi Trailer Tandem Semi Trailer Tank Trailer Saddle Mount/Trailer Boat Trailer 6 Utility Trailer House Trailer Commercial Motor Configuration 0,000 lbs or less Placarded 8 Tractor/Triple for Hazardous Materials 9 Truck more than 0,000 lbs (,6 Single-Unit Truck (-axle and GVWR kg), Cannot Classify more than 0,000 lbs (,6 kg)) 0 Bus/Large van (seats for 9- occupants, including driver) Single-Unit Truck ( or more axles) Truck Pulling Trailer(s) Truck Tractor (bobtail) 6 Truck Tractor/Semi-Trailer Truck Tractor/Double Truck 0,000 lbs (,6 kg) or less 0,00-6,000 lbs (,6-,9kg) More than 6,000 lbs (,9kg) Not Applicable Collision with Non-Fixed Object 0 Pedestrian Pedalcycle Railway (train, engine) Animal Motor in Transport Parked Motor 6 Work Zone/Maintenance Equipment Struck By Falling, Shifting Cargo or Anything Set in Motion by Motor 8 Other Non-Fixed Object Maneuver Action Straight Ahead Stopped in Traffic Turning Left Slowing Backing Negotiating a Curve Turning Right 6 Leaving Traffic Lane 6 Changing Lanes Entering Traffic Lane 8 Parked 0 Making U-Turn Overtaking/Passing 9 Ambulance 0 Fire Truck Farm Labor Transport School Bus Transit/Commuter Bus Trailer Type Intercity Bus Charter/Tour Bus 6 Shuttle Bus Farm Labor Bus CHARGE NO DRIVER LICENSE - NEVER HAD ONE ISSUED (IF VALID AT TIME C CHARGE CARELESS DRIVING Bus (seats for more than occupants, including driver) 8 Pole Trailer 9 Towed Cargo Body Type Intermodal 0 Auto Transport Van/Enclosed Box Container Chassis Hopper Towing Pole-Trailer Another 6 Cargo Tank Not Applicable No Cargo Flatbed (vehicle 0,000 lbs Bus 8 Dump (,6 kg) or less not 9 Concrete Mixer displaying HM placard 0 Auto Transport Garbage/Refuse Collision Fixed Object Log 9 Cable Barrier Emergency 9 Impact Attenuator/Crash Cushion 0 Concrete Traffic Barrier Use 0 Bridge Overhead Structure Other Traffic Barrier Bridge Pier or Support Tree (standing) Bridge Rail Utility Pole/Light Support Culvert Traffic Sign Support Curb Traffic Signal Support No Ditch 6 Other Post, Pole, or Support Yes 6 Embankment Fence Guardrail Face 8 Mailbox 8 Guardrail End 9 Other Fixed Object (wall, building, tunnel, etc.) Traffic Control For Defects CITATION NUMBER AFGZGP CITATION NUMBER AFGZFP NAME OF VIOLATOR STATUTE NUMBER CHARGE CITATION NUMBER No Controls School Zone Sign/ Traffic Control Signal 6 Stop Sign Yield Sign This 8 Flashing Signal 9 Railway Crossing 0 Person (including Flagman, Officer, Guard, etc.) None Brakes Wheels Tires Windows/ Lights (head, Windshield signal, tail) Mirrors 6 Steering 6 Truck Coupling Wipers Trailer Hitch/ 9 Exhaust System Safety Chains Other, Explain 0 Body, Doors in Power Train Suspension HSMV 9000 S

3 Driver Non-Motorist Passenger CURRENT ADDRESS (Number and Street) NAME SO-006 ANICETO PENCA CHAVEZ CITY & 8688 PHONE NUMBER () 6-88 Check if Recommend Driver Re-exam S. WASHINGTON AVE DATE OF BIRTH //98 DL Type A B C D/Chauffeur E/Operator 6 E/Oper-Rest None Driver Distracted By SEX: Male Female Not Distracted Electronic Communication s (cell phone, etc. Other Electronic (navigation device, DVD player) DRIVER VISION OBSTRUCTIONS Vision Not Obscured Inclement Weather Parked/Stopped Trees/Crops/Bushes Motor Seating Position: Seat Left Midde Right Other (explain in narrative) Required Endorsements Yes No No Req. Endorsement Non-Motorist Description Pedestrian Other Pedestrian (wheelchari, person in a building, skater, pedestrian conveyance, etc. Bicyclist Other Cyclist Occupant of Motor Not in Transport (parked, etc.) 6 Occupant of a Non-Motor Transportation Unknown Type of Non-Motorist SUSPECTED ALCOHOL USE: No Yes Row Front Second Third Fourth Other Row None Safety Equipment Helmet Protective Pads Used (elbows, knees, shins, etc.) Reflective Clothing (jacket, backpack, etc.) Other Inside the (explain in narrative) External Distraction (outside the vehicle, explain in narrative) 6 Texting Inattentive Load on 6 Building/Fixed Object Signs/Billboards 8 Fog ALCOHOL TESTED: Test Not Given Test Refused Test Given, if Tested DRIVERS LICENSE NUMBER EXPIRES 9 Smoke 0 Glare All Other, Explain in SEAT ROW LOCATION: (LOC) Other Not Applicable Sleeper Section of Truck Cab Other Enclosed Cargo Area Unenclosed Cargo Area Trailing Unit 6 Riding on Motor Exterior (nontrailing unit) Lighting 6 Not Applicable Other, Explain in st nd DRIVER Drivers Actions No Contribution Action Operated MV in Carelss or Negligent Manner Failed to Yield Right-of-Way Improper Backing 6 Improper Turn 0 Followed too Closely Ran Red Light Drove too Fast for Conditions Ran Stop Sign Improper Passing Exceeded Posted Speed Wrong Side of Wrong Way Failed to Keep in Proper Lane Helmet Use (HU) Ejection (EJECT) Not Ejected Ejected, Totally Ejected, Partially Not Applicable NON-MOTORIST DOT-Compliant Motorcycle Helmet Other Helmet No Helmet ADDITIONAL PASSENGERS NAME DATE OF BIRTH INJ SEX LOC: S R O EJECT HU EP ABD RS at Time of Crash 6 Ran off Roadway Disregarded other Traffic Sign 8 Disregarded Other Road Markings 9 Over-Correcting/Over Steering 0 Swerved or Avoided : Due to Wind, Slippery Surface, MV, Object, Non-Motorist in Roadway, etc. Operated MV in Erratic, Reckless or Agreessive Manner Other Contributing Action 6 INJURY SEVERITY (INJ) None Incapacitating Possible Fatal (within 0 days) Non-Incapacitating 6 Non-Traffic Fatality Eye Protection (EP) Yes No Not Applicable Air Bag Deployed Deployed-Other Not Applicable (knee, air belt, etc.) Not Deployed 6 Deployed- Deployed-Front Combination Deployed-Side Deployed-Curtain 88 Deployment Unknown Non-Motorist Location At Time of Crash 8 Sidewalk Intersection - Marked Crosswalk 9 Median/Crossing Island Intersection - Unmarked Crosswalk 0 Driveway Access Intersection - Other Midblock - Marked Crosswalk Shared-Use Path or Trail Midblock - Marked Crosswalk Non-Trafficway Area Travel Lane - Other Location 6 Bicycle Lane shoulder/roadside st nd ALCOHOL TEST TYPE: Blood Breath Urine Other, Explain in OTHER Non-Motorist Actions/Circumstances No Improper Action Dart/Dash Failure to Yield Right-of-Way Failure to Obey Traffic Signs Signals, or Officer In Roadway Improperly (standing, lying, working, playing) 6 Disabled Related (working on, pushing, leaving/approaching) ALCOHOL TEST RESULT: PENDING COMPLETED 88 UNKNOWN Entering/Exiting Parked/Standing 8 Inattentive (talking, eating, etc) 9 Not Visible (dark clothing, no lighting, etc.) ALCOHOL/DRUG/EMS BAC SUSPECTED DRUG USE: No Yes rd th Action Prior to Crash Crossing Roadway Waiting to Cross Roadway Walking/Cycling Along Roadway with Traffic (in or adjacent to travel lane) Walking/Cycling Along Roadway Against Traffic (in or adjacent to travel lane) Condition At Time of Crash Apparently Normal Asleep or Fatiuged Ill (sick) or Fainted 6 Seizure, Epilespsy, Blackout Physically Impaired 8 Emotional (depression, angry, disturbed, etc.) 9 Under the Influence of Medications/Drugs/Alcohol Restraint Systems (RS) Not Applicable (non-motorist) None Used - Motor Occupant Shoulder and Lap Belt Used Shoulder Belt Only Used Lap Belt Only Used 6 Restraint Used - Type Unknown Child Restraint System - Forward Facing 8 Child Restraint System - Rear Facing 9 Booster Seat 0 Child Restraint Type Unknown 0 Improper Turn/Merge Improper Passing Wrong-Way Riding or Walking DRUG TESTED: Test Not Given Test Refused Test Given, if Tested Walking/Cycling on Sidewalk 6 In Roadway -- Other (working, playing, etc.) Adjacent to Raodway (e.g., shoulder, median) 8 Going to or from School (K-) 9 Working in Trafficway (incident response) 0 None DRUG TEST TYPE: DRUG TEST RESULT: Blood Positive Urine Negative Other, Pending Explain in Not Transported EMS Law Enforcement CURRENT ADDRESS (Number and Street) CITY Not Transported EMS Law Enforcement NAME DATE OF BIRTH INJ SEX LOC: S R O EJECT HU EP ABD RS CURRENT ADDRESS (Number and Street) CITY Not Transported EMS Law Enforcement HSMV 9000 S

4 NARRATIVE SO VEHICLE WAS TRAVELING WESTBOUND ON WEST BAY DR AND VEHICLE WAS TRAVELING NORTHBOUND ON INDIAN ROCKS RD. AS BOTH VEHICLES APPROACH THE INTERSECTION OF INDIAN ROCKS RD AND WEST BAY DR. VEHICLE ONE HAD THE RED LIGHT AND VEHICLE TWO HAD THE GREEN LIGHT. VEHICLE TWO WAS TRAVELING NORTH BOUND, THROUGH THE LIGHT WHEN VEHICLE ONE STRUCK VEHICLE TWO ON THE PASSENGER SIDE DOOR. WHICH SPUN VEHICLE AROUND CLOCKWISE UNTIL IT WAS FACING WEST. THE IMPACT CAUSE THE FRONT TWO AIRBAGS TO DEPLOY IN VEHICLE TWO. VEHICLE ONE'S DRIVER D HE DIDN'T SEE THE RED LIGHT UNTIL IT WAS TOO LATE. VEHICLE ONE DRIVER D IT WAS HIS FAULT. THE WITNESS SANDRA TURNER D AS SHE WAS LIVING THE SPEEDWAY SHE OBSERVED THE LIGHT TO BE GREEN FOR NORTH / SOUTH TRAFFIC AND SAW THE MITSUBISHI COMING OUT OF NO WHERE AND STRIKING THE BMW. VEHICLE TWO'S DRIVER COMPLAINED ABOUT NECK AND BACK PAIN AND HAD TO BE TRANSPORTED TO THE HOSPITAL. VEHICLE ONE DRIVER AND PASSENGER REFUSED MEDICAL TREATMENT FROM FIRE RESCUE. VEHICLE ONE DRIVER WAS CITED FOR CARELESS DRIVING AND FOR OPERATING A MOTOR VEHICLE WITHOUT A DRIVERS LICENSE NAME MARTA ADDITIONAL PASSENGERS DATE OF BIRTH INJ QUEZADA //98 SEX LOC: S R O EJECT HU EP ABD RS CURRENT ADDRESS (Number and Street) S. WASHINGTON AVE CITY 6 Not Transported EMS Law Enforcement NAME DATE OF BIRTH INJ SEX LOC: S R O EJECT HU EP ABD RS CURRENT ADDRESS (Number and Street) CITY Not Transported EMS Law Enforcement ADDITIONAL VIOLATIONS NAME OF VIOLATOR STATUTE NUMBER CHARGE CITATION NUMBER NAME OF VIOLATOR STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER ID/BADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. 8 DEPUTY J. DARBY PINELLAS COUNTY SO SHERIFF'S OFFICE (SO) HSMV 9000 S

5 DIAGRAM REPORTING AGENCY CASE NUMBER SO-006 HSMV CRASH REPORT NUMBER 8688 HSMV 9000 S

6 in Transport Parked Motor Working Hit and Run No Yes YEAR 00 INSURANCE COMPANY (DRIVER) VEHICLE LICENSE NUMBER RDEON MAKE BMW ALL FIRE AND CASUALTY INSURANCE Check if Commercial MODEL M INSURANCE POLICY NUMBER SO-006 REGISTRATION EXPIRES 08/06/06 STYLE DOOR SEDAN Towed due to Damage: No Yes Check if Permanent COLOR SILVER - SIL VIN 8688 UMCL96LJ8 DAMAGE: Disabling Functional None VEHICLE REMOVED BY JOE'S TOWING EST. AMOUNT Minor $, Rotation. Owner Request. Driver. Other, Explain in NAME OF VEHICLE OWNER (CHECK IF BUSINESS) CURRENT ADDRESS CITY & ZIP KAREN WESTFALLTORR NMN ES 86 PINE ST 6 Trailer LICENSE NUMBER REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES One: Trailer Two: LICENSE NUMBER REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES VEHICLE TRAVELING N HAZ. MAT. RELEASED No Yes MOTOR CARRIER NAME S E W Off-Road Unknown ON STREET, ROAD, HIGHWAY INDIAN ROCKS RD HAZ. MAT. PLACARD NUMBER CLASS No Yes US DOT NUMBER Area of Initial Impact AT EST. SPEED POSTED SPEED Undercarriage 8 9 Overturn 9 0 Windshield 0 Trailer TOTAL LANES Most Damaged Area MOTOR CARRIER ADDRESS CITY PHONE NUMBER Body Type Low Speed Trafficway Commercial Motor Configuration 0,000 lbs or less Placarded 8 Tractor/Triple 6 (Sport) Utility Two-Way, Not Divided for Hazardous Materials Cargo Van (0,000 lbs Two-Way, Not Divided, with a 9 Truck more than 0,000 lbs (,6 (,6 kg) or less) Continuous Left Turn Lane Single-Unit Truck (-axle and GVWR kg), Cannot Classify more than 0,000 lbs (,6 kg)) 0 Bus/Large van (seats for 9- Passenger Car 8 Motor Coach Two-Way, Divided, Unprotected Passenger Van 9 Other Light Trucks (0,000 lbs (painted > feet) Median Single-Unit Truck ( or more axles) occupants, including driver) Truck Pulling Trailer(s) Pickup (,6 kg) or less) Two-Way, Divided, Positive Bus (seats for more than Motor Home 0 Medium/Heavy Trucks (more Median Barrier Truck Tractor (bobtail) occupants, including driver) 6 Truck Tractor/Semi-Trailer 8 Bus than 0,000 lbs (,6 kg)) One-Way Trafficway Truck Tractor/Double Truck Motorcycle Farm Labor Moped Trailer Type All Terrain (ATV) Single Semi Trailer 8 Pole Trailer Tandem Semi Trailer 9 Towed Cargo Body Type Comm/Non-Commercial TRAILER TRAILER Intermodal Tank Trailer 0 Auto Transport Van/Enclosed Box Container Chassis Saddle Mount/Trailer Interstate Carrier Hopper Towing Boat Trailer Intrastate Carrier Pole-Trailer Another 6 Utility Trailer Not in Commerce/Government 6 Cargo Tank Not Applicable House Trailer No Cargo Not in Commerce/Other Truck Flatbed (vehicle 0,000 lbs Bus Most Harmful Event Non-Collision 0,000 lbs (,6 kg) or less 8 Dump (,6 kg) or less not Comm Overturn/Rollover 0,00-6,000 lbs (,6-,9kg) 9 Concrete Mixer displaying HM placard GVWR/GCWR More than 6,000 lbs (,9kg) 0 Auto Transport Fire/Explosion Not Applicable Garbage/Refuse Immersion Jackknife Collision with Non-Fixed Object Collision Fixed Object Log Cargo/Equipment Loss or Shift 0 Pedestrian 9 Cable Barrier Emergency 9 Impact Attenuator/Crash Cushion 6 Fell/Jumped From Motor Pedalcycle 0 Concrete Traffic Barrier Use 0 Bridge Overhead Structure Thrown or Falling Object Railway (train, engine) Other Traffic Barrier Bridge Pier or Support Sequence of Events 8 Ran into Water/Canal Animal Tree (standing) Bridge Rail 9 Other Non-Collision Motor in Transport Utility Pole/Light Support Culvert st nd Parked Motor Traffic Sign Support [0-6 Sequence of Events only] 6 Work Zone/Maintenance Curb Traffic Signal Support No 0 equipment Failure (blown tire, Equipment Ditch 6 Other Post, Pole, or Support Yes brake failure, etc.) Struck By Falling, Shifting Cargo or 6 Embankment Fence Separation of Units Anything Set in Motion by Motor Guardrail Face 8 Mailbox rd th Ran Off Roadway, Right 8 Guardrail End 9 Other Fixed Object (wall, Ran Off Roadway, Left 8 Other Non-Fixed Object building, tunnel, etc.) Cross Median Maneuver Action Traffic Control For Defects Cross Centerline Straight Ahead Stopped in Traffic This Roadway Grade 6 Downhill Runaway Turning Left Slowing Backing Negotiating a Curve Level 8 Flashing Signal None Hillcrest Turning Right 6 Leaving Traffic Lane 9 Railway Crossing Roadway Alignment No Controls Brakes Wheels Uphill 6 Changing Lanes Entering Traffic Lane School Zone Sign/ Tires Windows/ Downhill Straight 8 Parked 0 Person (including Lights (head, Windshield Sag (bottom) Curve Right 0 Making U-Turn Flagman, Officer, Traffic Control signal, tail) Mirrors Curve Left Overtaking/Passing Guard, etc.) Signal 6 Steering 6 Truck Coupling Special Function No Special Function 9 Ambulance Intercity Bus 6 Stop Sign Wipers Trailer Hitch/ Farm 0 Fire Truck Charter/Tour Bus Yield Sign 9 Exhaust System Safety Chains of Motor Other, Explain Police Farm Labor Transport 6 Shuttle Bus 0 Body, Doors in Taxi School Bus Farm Labor Bus Power Train 8 Military Transit/Commuter Bus Suspension VIOLATIONS NAME OF VIOLATOR STATUTE NUMBER CHARGE CITATION NUMBER NAME OF VIOLATOR STATUTE NUMBER CHARGE CITATION NUMBER NAME OF VIOLATOR STATUTE NUMBER CHARGE CITATION NUMBER HSMV 9000 S 6

7 Driver Non-Motorist Passenger CURRENT ADDRESS (Number and Street) NAME KAREN SO-006 WESTFALLTORRES CITY & 8688 PHONE NUMBER () -8 Check if Recommend Driver Re-exam 86 PINE ST DATE OF BIRTH 8/6/960 DL Type A B C D/Chauffeur E/Operator 6 E/Oper-Rest None Driver Distracted By SEX: Male Female Not Distracted Electronic Communication s (cell phone, etc. Other Electronic (navigation device, DVD player) DRIVER VISION OBSTRUCTIONS Vision Not Obscured Inclement Weather Parked/Stopped Trees/Crops/Bushes Motor Seating Position: Seat Row Other Left Midde Right Other (explain in narrative) Non-Motorist Description Pedestrian Other Pedestrian (wheelchari, person in a building, skater, pedestrian conveyance, etc. Bicyclist Other Cyclist Occupant of Motor Not in Transport (parked, etc.) 6 Occupant of a Non-Motor Transportation Unknown Type of Non-Motorist SUSPECTED ALCOHOL USE: No Yes Front Second Third Fourth Other Row Required Endorsements Yes No No Req. Endorsement DRIVERS LICENSE NUMBER W Other Inside the (explain in narrative) External Distraction (outside the vehicle, explain in narrative) 6 Texting Inattentive st nd ADDITIONAL PASSENGERS NAME DATE OF BIRTH INJ SEX LOC: S R O EJECT HU EP ABD RS Drivers Actions No Contribution Action Operated MV in Carelss or Negligent Manner Failed to Yield Right-of-Way Improper Backing 6 Improper Turn 0 Followed too Closely Ran Red Light Drove too Fast for Conditions Ran Stop Sign Improper Passing Exceeded Posted Speed Wrong Side of Wrong Way Failed to Keep in Proper Lane Load on 9 Smoke 6 Building/Fixed Object 0 Glare Signs/Billboards 8 Fog All Other, Explain in Helmet Use None Safety Equipment Lighting Helmet 6 Not Applicable Protective Pads Used Other, Explain (elbows, knees, shins, etc.) in Reflective Clothing (jacket, backpack, etc.) ALCOHOL TESTED: Test Not Given Test Refused Test Given, if Tested Not Transported EMS Law Enforcement LOCATION: (LOC) Ejection (EJECT) Not Ejected Ejected, Totally Ejected, Partially Not Applicable NON-MOTORIST (HU) DOT-Compliant Motorcycle Helmet Other Helmet No Helmet EXPIRES 8/6/00 at Time of Crash 6 Ran off Roadway Disregarded other Traffic Sign 8 Disregarded Other Road Markings 9 Over-Correcting/Over Steering 0 Swerved or Avoided : Due to Wind, Slippery Surface, MV, Object, Non-Motorist in Roadway, etc. Operated MV in Erratic, Reckless or Agreessive Manner Other Contributing Action 6 INJURY SEVERITY (INJ) None Incapacitating Possible Fatal (within 0 days) Non-Incapacitating 6 Non-Traffic Fatality Eye Protection (EP) Yes No Not Applicable Air Bag Deployed Deployed-Other Not Applicable (knee, air belt, etc.) Not Deployed 6 Deployed- Deployed-Front Combination Deployed-Side Deployed-Curtain 88 Deployment Unknown Non-Motorist Location At Time of Crash 8 Sidewalk Intersection - Marked Crosswalk 9 Median/Crossing Island Intersection - Unmarked Crosswalk 0 Driveway Access Intersection - Other Midblock - Marked Crosswalk Shared-Use Path or Trail Midblock - Marked Crosswalk Non-Trafficway Area Travel Lane - Other Location 6 Bicycle Lane shoulder/roadside st nd ALCOHOL TEST TYPE: Blood Breath Urine Other, Explain in SUNSTAR SEAT ROW OTHER Not Applicable Sleeper Section of Truck Cab Other Enclosed Cargo Area Unenclosed Cargo Area Trailing Unit 6 Riding on Motor Exterior (nontrailing unit) EMS AGENCY NAME OR ID Non-Motorist Actions/Circumstances No Improper Action Dart/Dash Failure to Yield Right-of-Way Failure to Obey Traffic Signs Signals, or Officer In Roadway Improperly (standing, lying, working, playing) 6 Disabled Related (working on, pushing, leaving/approaching) ALCOHOL/DRUG/EMS BAC ALCOHOL TEST RESULT: PENDING COMPLETED 88 UNKNOWN DRIVER Entering/Exiting Parked/Standing 8 Inattentive (talking, eating, etc) 9 Not Visible (dark clothing, no lighting, etc.) EMS RUN NUMBER 69 SUSPECTED DRUG USE: No Yes rd th Action Prior to Crash Crossing Roadway Waiting to Cross Roadway Walking/Cycling Along Roadway with Traffic (in or adjacent to travel lane) Walking/Cycling Along Roadway Against Traffic (in or adjacent to travel lane) Condition At Time of Crash Apparently Normal Asleep or Fatiuged Ill (sick) or Fainted 6 Seizure, Epilespsy, Blackout Physically Impaired 8 Emotional (depression, angry, disturbed, etc.) 9 Under the Influence of Medications/Drugs/Alcohol Restraint Systems (RS) Not Applicable (non-motorist) None Used - Motor Occupant Shoulder and Lap Belt Used Shoulder Belt Only Used Lap Belt Only Used 6 Restraint Used - Type Unknown Child Restraint System - Forward Facing 8 Child Restraint System - Rear Facing 9 Booster Seat 0 Child Restraint Type Unknown 0 Improper Turn/Merge Improper Passing Wrong-Way Riding or Walking DRUG TESTED: Test Not Given Test Refused Test Given, if Tested Walking/Cycling on Sidewalk 6 In Roadway -- Other (working, playing, etc.) Adjacent to Raodway (e.g., shoulder, median) 8 Going to or from School (K-) 9 Working in Trafficway (incident response) 0 None DRUG TEST TYPE: Blood Urine Other, Explain in LARGO MEDICAL DRUG TEST RESULT: Positive Negative Pending MEDICAL FACILITY TRANSPORTED TO CURRENT ADDRESS (Number and Street) CITY Not Transported EMS Law Enforcement NAME DATE OF BIRTH INJ SEX LOC: S R O EJECT HU EP ABD RS CURRENT ADDRESS (Number and Street) CITY Not Transported EMS Law Enforcement HSMV 9000 S