TRAFFIC CRASH REPORT *DENOTES MANDATORY FIELD FOR SUPPLEMENT REPORT LOCAL REPORT NUMBER *

Transcription

1 PHOTOS SECONDARY CRASH COUNTY* LOCATION REFERENCE 83 CR TRAFFIC CRASH REPORT *DENOTES MANDATORY FIELD FOR SUPPLEMENT REPORT * LOCAL INFORMATION OH -2 OH-P LOCALITY* - CITY 2 - VILLAGE TOWNSHIP ROUTE TYPE ROUTE NUMBER ROUTE TYPE ROUTE NUMBER REFERENCE POINT US - INTERSECTION 2 - MILE POST 3 - HOUSE # DISTANCE FROM REFERENCE 5.00 OH -3 OTHER PRIVATE PROPERTY DIRECTION FROM REFERENCE REPORTING AGENCY NAME * Hamilton Township LOCATION: CITY, VILLAGE, TOWNSHIP* Hamilton (Township of) - NORTH - WEST DISTANCE UNIT OF MEASURE - MILES 2 - FEET YARDS LOCATION OF FIRST HARMFUL EVENT - ON ROADWAY 2 - ON SHOULDER 3 - IN MEDIAN - ON ROADSIDE 5 - ON GORE 6 - OUTSIDE TRAFFIC WAY 7 - ON RAMP 8 - OFF RAMP 35 PREFIX - NORTH - WEST PREFIX - NORTH - WEST LOCATION ROAD NAME US AT STUBBS MILL REFERENCE ROAD NAME (ROAD, MILEPOST, HOUSE #) ROUTE TYPE IR - INTERSTATE ROUTE (TP) US - FEDERAL US ROUTE SR - STATE ROUTE CR - NUMBERED COUNTY ROUTE TR - NUMBERED TOWNSHIP ROUTE 9 - CROSSOVER 0 - DRIVEWAY/ALLEY ACCESS - RAILWAY GRADE CROSSING 2 - SHARED USE PATHS OR TRAILS 3 - BIKE LANE - TOLL BOOTH AL - ALLEY AV - AVENUE BL - BOULEVARD CR - CIRCLE CT - COURT DR - DRIVE HE - HEIGHTS ROAD TYPE HW - HIGHWAY LA - LANE MP - MILEPOST OV - OVAL PK - PARKWAY PI - PIKE PL - PLACE NCIC * HIT/SKIP NUMBER OF UNITS SOLVED 2 - UNSOLVED RD - ROAD SQ - SQUARE ST - STREET TE - TERRACE TL - TRAIL WA - WAY MANNER OF CRASH COLLISION/IMPACT - NOT COLLISION - REAR-TO-REAR BETWEEN 5 - BACKING TWO MOTOR 6 - ANGLE S IN TRANSPORT 7 - SIDESWIPE, SAME DIRECTION 8 - SIDESWIPE, OPPOSITE DIRECTION 2 - REAR-END 3 - HEAD-ON ROAD TYPE ROAD TYPE CRASH DATE / TIME* 03/2/209 06:36 LATITUDE DECIMAL DEGREES LONGITUDE DECIMAL DEGREES ROADWAY 98 INTERSECTION RELATED WITHIN INTERSECTION OR ON APPROACH WITHIN INTERCHANGE AREA ROADWAY DIVIDED DIRECTION OF TRAVEL - NORTH - WEST UNIT IN ERROR 98 - ANIMAL 99 - UNKNOWN CRASH SEVERITY 5 - FATAL 2 - SERIOUS INJURY SUSPECTED 3 - MINOR INJURY SUSPECTED - INJURY POSSIBLE 5 - PROPERTY DAMAGE ONLY NUMBER OF APPROACHES MEDIAN TYPE - DIVIDED FLUSH MEDIAN ( < FEET ) 2 - DIVIDED FLUSH MEDIAN ( FEET ) 3 - DIVIDED, DEPRESSED MEDIAN - DIVIDED, RAISED MEDIAN (ANY TYPE) 5 WORK ZONE RELATED WORKERS PRESENT LAW ENFORCEMENT PRESENT ACTIVE SCHOOL ZONE LIGHT CONDITION - DAYLIGHT 2 - DAWN/DUSK 3 - DARK - LIGHTED ROADWAY - DARK - ROADWAY NOT LIGHTED 5 - DARK - UNKNOWN ROADWAY LIGHTING WORK ZONE TYPE - LANE CLOSURE 2 - LANE SHIFT/ CROSSOVER 3 - WORK ON SHOULDER OR MEDIAN - INTERMITTENT OR MOVING WORK 5 - OTHER - CLEAR 2 - CLOUDY LOCATION OF CRASH IN WORK ZONE WEATHER - BEFORE THE ST WORK ZONE WARNING SIGN 2 - ADVANCE WARNING AREA 3 - TRANSITION AREA - ACTIVITY AREA 5 - TERMINATION AREA 3 - FOG, SMOG, SMOKE 8 - BLOWING SAND, SOIL, DIRT, SNOW - RAIN 5 - SLEET, HAIL 6 - SNOW 7 - SEVERE CROSSWINDS 9 - FREEZING RAIN OR FREEZING DRIZZLE CONTOUR - STRAIGHT LEVEL 2 - STRAIGHT GRADE 3 - CURVE LEVEL - CURVE GRADE 9 - OTHER /UNKNOWN - DRY 2 - WET 3 - SNOW CONDITIONS - ICE 5 - SAND, MUD, DIRT, OIL, GRAVEL 6 - WATER (STANDING, MOVING) 7 - SLUSH SURFACE 2 - CONCRETE 2 - BLACKTOP, BITUMINOUS, ASPHALT 3 - BRICK/BLOCK - SLAG, GRAVEL, STONE 5 - DIRT 9 - OTHER / UNKNOWN NARRATIVE Unit # was traveling WB on US near CR 35. Unit # then struck a deer that had entered the roadway, causing disabling damage. CRASH REPORTED DATE / TIME 03/2/209 06:36 TOTAL TIME OTHER ROADWAY CLOSED INVESTIGATION TIME 0 5 TOTAL MINUTES 67 DISPATCH DATE / TIME 03/2/209 06:36 OFFICER'S NAME* Ptl. Jordan Elzey OFFICER'S BADGE NUMBER* ARRIVAL DATE / TIME 03/2/209 06:5 CHECKED OFFICER'S NAME* Viel, Sgt. Terry SCENE CLEARED DATE / TIME 03/2/209 07:28 CHECKED OFFICER'S BADGE NUMBER* 9 X REPORT POLICE AGENCY MOTORIST X SUPPLEMENT (CORRECTION OR ADDITION TO AN EXISTING REPORT SENT TO ODPS) PAGE OF

2 O W N E R V E H I C L E E V E N T S (s) UNIT # OWNER ( MEYER, MATTHEW, L OWNER ( LP STATE OH INSURANCE X VERIFIED COMMERCIAL UNIT TYPE SPECIAL FUNCTION DEFECTS NON- MOTORIST LOCATION 3 ACTION LICENSE PLATE # HPF TURN SIGNALS 2 - HEAD LAMPS 3 - TAIL LAMPS TYPE OF USE GOVERNMENT - PASSENGER CAR 2 - PASSENGER VAN (MINIVAN) 3 - SPORT UTILITY - PICK UP - INTERSECTION - MARKED CROSSWALK 2 - INTERSECTION - UNMARKED CROSSWALK 3 - INTERSECTION - OTHER IN EMERGENCY RESPONSE - BRAKES 5 - STEERING SAME AS DRIVER) # S 6 - VAN (9-5 SEATS) 7 - MOTORCYCLE 2-WHEELED 8 - MOTORCYCLE 3-WHEELED 9 - AUTOCYCLE 0 - MOPED OR MOTORIZED BICYCLE 5 - CARGO VAN - ALL TERRAIN (ATV/UTV) # OF TRAILING UNITS - NONE 2 - TAXI 3 - ELECTRONIC RIDE SHARING - SCHOOL TRANSPORT 5 - BUS - TRANSIT/COMMUTER - NON-CONTACT 2 - NON-COLLISION 3 - STRIKING - STRUCK 5 - BOTH STRIKING & STRUCK PRE-CRASH ACTIONS - NONE 2 - FAILURE TO YIELD 3 - RAN RED LIGHT - RAN STOP SIGN 5 - UNSAFE SPEED CONTRIBUTING 6 - IMPROPER TURN CIRCUMSTANCES 7 - LEFT OF CENTER SEQUENCE OF EVENTS INSURANCE COMPANY SAFECO - OVERTURN/ROLLOVER 2 - FIRE/EXPLOSION 3 - IMMERSION - JACKKNIFE 5 - CARGO / EQUIPMENT LOSS OR SHIFT 6 - EQUIPMENT FAILURE 25 - IMPACT ATTENUATOR / CRASH CUSHION 26 - BRIDGE OVERHEAD STRUCTURE 27 - BRIDGE PIER OR ABUTMENT 28 - BRIDGE PARAPET 29 - BRIDGE RAIL 30 - GUARDRAIL FACE SAME AS DRIVER) 5539 APPALOOSA CIRLCE, MORROW, OH, 552 COMMERCIAL CARRIER: NAME, ADDRESS, CITY, STATE, ZIP INTERLOCK DEVICE EQUIPPED 2 CARGO BODY TYPE UNIT HIT/SKIP UNIT WAS OPERATING IN AUTONOMOUS MODE WHEN CRASH OCCURRED? - YES 2 - NO - NO CARGO BODY TYPE / NOT APPLICABLE 2 - BUS 3 - TOWING ANOTHER MOTOR 6 - BUS - CHARTER/TOUR 7 - BUS - INTERCITY 8 - BUS - SHUTTLE 9 - BUS - OTHER 0 - AMBULANCE - LOGGING 6 - TIRE BLOWOUT - MIDBLOCK - MARKED CROSSWALK 5 - TRAVEL LANE - OTHER LOCATION 6 - BICYCLE LANE - STRAIGHT AHEAD 2 - BACKING 3 - CHANGING LANES - OVERTAKING/PASSING 5 - MAKING RIGHT TURN 6 - MAKING LEFT TURN 7 - MAKING U-TURN 8 - ENTERING TRAFFIC LANE 8 - FOLLOWING TOO CLOSE /ACDA 9 - IMPROPER LANE CHANGE 0 - IMPROPER PASSING - DROVE OFF ROAD 2 - IMPROPER BACKING FIRST HARMFUL EVENT IDENTIFICATION # GZH57B69998 INSURANCE POLICY # US DOT # WEIGHT GVWR/GCWR - 0K LBS. 2-0,00-26K LBS. 3 - > 26K LBS. 0 AUTONOMOUS MODE LEVEL 5 - INTERMODAL CONTAINER CHASSIS 6 - CARGOVAN /ENCLOSED BOX 7 - SEPARATION OF UNITS 8 - RAN OFF ROAD RIGHT 9 - RAN OFF ROAD LEFT 0 - CROSS MEDIAN - CROSS CENTERLINE - OPPOSITE DIRECTION OF TRAVEL 35 - MEDIAN CONCRETE BARRIER 36 - MEDIAN OTHER BARRIER 37 - TRAFFIC SIGN POST K GOLF CART 3 - SNOWMOBILE - SINGLE UNIT TRUCK 5 - SEMI-TRACTOR 6 - FARM EQUIPMENT 7 - MOTORHOME 0 - NO AUTOMATION - DRIVER ASSISTANCE 2 - PARTIAL AUTOMATION - FIRE 2 - MILITARY 3 - POLICE - PUBLIC UTILITY 5 - CONSTRUCTION EQUIP. 7 - GRAIN/CHIPS/GRAVEL 8 - POLE 9 - CARGO TANK 0 - FLAT BED 7 - WORN OR SLICK TIRES 9 - MOTOR TROUBLE 8 - TRAILER EQUIPMENT DEFECTIVE 7 - SHOULDER/ROADSIDE 8 - SIDEWALK 9 - MEDIAN/CROSSING ISLAND 9 - LEAVING TRAFFIC LANE 0 - PARKED - SLOWING OR STOPPED IN TRAFFIC 2 - DRIVERLESS 3 - NEGOTIATING A CURVE - ENTERING OR CROSSING SPECIFIED LOCATION 3 - IMPROPER START FROM A PARKED - STOPPED OR PARKED ILLEGALLY 5 - SWERVING TO AVOID 6 - WRONG WAY 7 - VISION OBSTRUCTION 5 - PEDALCYCLE 6 - RAILWAY 7 - ANIMAL - FARM 8 - ANIMAL - DEER MOST HARMFUL EVENT 0 - DISABLED FROM PRIOR ACCIDENT MAKE CHEVROLET COLOR BLU MODEL MALIBU TOWED : COMPANY NAME PHIPPS HAZARDOUS MATERIAL MATERIAL CLASS # PLACARD ID # RELEASED PLACARD 8 - LIMO (LIVERY ) 9 - BUS (6+ PASSENGERS) 20 - OTHER 2 - HEAVY EQUIPMENT - ANIMAL WITH RIDER OR ANIMAL-DRAWN 6 - FARM 7 - MOWING 8 - SNOW REMOVAL 9 - TOWING 20 - SAFETY SERVICE PATROL 0 - DRIVEWAY ACCESS - SHARED USE PATHS OR TRAILS 2 - FIRST RESPONDER AT INCIDENT SCENE 5 - WALKING, RUNNING, JOGGING, PLAYING 6 - WORKING 7 - PUSHING 8 - APPROACHING OR LEAVING 23 - PEDESTRIAN/SKATER 2 - WHEELCHAIR (ANY TYPE) 25 - OTHER NON-MOTORIST 26 - BICYCLE 27 - TRAIN 9 - STANDING 20 - OTHER NON-MOTORIST 8 - OPERATING DEFECTIVE EQUIPMENT 9 - LOAD SHIFTING /FALLING/SPILLING 20 - IMPROPER CROSSING 2 - LYING IN ROADWAY - NOT DISCERNIBLE NON-COLLISION 2 - DOWNHILL RUNAWAY 9 - ANIMAL -OTHER 3 - OTHER NON-COLLISION 20 - MOTOR IN - PEDESTRIAN TRANSPORT 2 - PARKED MOTOR - WORK ZONE MAINTENANCE EQUIPMENT COLLISION WITH FIXED OBJECT - STRUCK 3 - GUARDRAIL END 32 - PORTABLE BARRIER 38 - OVERHEAD SIGN POST 39 - LIGHT / LUMINARIES 5 - EMBANKMENT 6 - FENCE 33 - MEDIAN CABLE BARRIER SUPPORT 7 - MAILBOX 3 - MEDIAN GUARDRAIL 0 - UTILITY POLE 8 - TREE BARRIER - OTHER POST, POLE 9 - FIRE HYDRANT OR SUPPORT 2 - CULVERT 3 - CURB - DITCH OWNER PHONE:INCLUDE AREA CODE ( COMMERCIAL CARRIER PHONE: INCLUDE AREA CODE 50 - WORK ZONE MAINTENANCE EQUIPMENT 5 - WALL YEAR CONDITIONAL AUTOMATION - HIGH AUTOMATION 5 - FULL AUTOMATION 99 - UNKNOWN OR HIT/SKIP 2 - MAIL CARRIER - DUMP 2 - CONCRETE MIXER 3 - AUTO TRANSPORTER - GARBAGE/REFUSE UNKNOWN SAME AS DRIVER) 2 - STANDING OUTSIDE DISABLED 23 - OPENING DOOR INTO ROADWAY 99 - OTHER IMPROPER ACTION 23 - STRUCK FALLING, SHIFTING CARGO OR ANYTHING SET IN MOTION A MOTOR 2 - OTHER MOVABLE OBJECT 52 - BUILDING 53 - TUNNEL 5 - OTHER FIXED OBJECT - NONE 2 - MINOR DAMAGE 2 FROM DAMAGE SCALE 9 - UNKNOWN DAMAGED AREA(S) INDICATE ALL THAT APPLY - NO DAMAGE [ 0 ] - TOP [ 3 ] TRAFFICWAY FLOW - ONE-WAY 2 - TWO-WAY # OF THROUGH LANES ON ROAD UNIT SPEED FUNCTIONAL DAMAGE - DISABLING DAMAGE - UNIT NOT AT SCENE [ 6 ] 6 - UNDERCARRIAGE [ ] - ALL AREAS [ 5 ] TRAFFIC CONTROL - ROUNDABOUT 2 - SIGNAL 3 - FLASHER UNIT / NON-MOTORIST DIRECTION 3 TO POSTED SPEED 55 D A M A G E INITIAL POINT OF CONTACT 0 - NO DAMAGE -2 - REFER TO UNIT DIAGRAM 3 - TOP T R A F F I C - NORTH - WEST - UNDERCARRIAGE 5 - NOT AT SCENE 99 - UNKNOWN DETECTED SPEED - STATED / ESTIMATED SPEED 2 - CALCULATED / EDR 3 - UNDETERMINED - STOP SIGN 5 - YIELD SIGN RAIL GRADE CROSSING - NOT INVLOVED 6 - NO CONTROL 2 - INVOLVED-ACTIVE CROSSING 3 - INVOLVED-PASSIVE CROSSING 5 - NORTHEAST 6 - NORTHWEST 7 - SOUTHEAST 8 - SOUTHWEST PAGE 2 OF

3 UNIT # DATE OF BIRTH AGE GENDER 5539 APPALOOSA CIRCLE, MORROW, OH, 552 INJURIES 5 MEYER, MATTHEW, L INJURED OL STATE OPERATOR LICENSE NUMBER OH SH3077 EMS AGENCY (NAME) INJURED TO: MEDICAL FACILITY (NAME, CITY) SAFETY EQUIPMENT ENDORSEMENT RESTRICTION SELECT UP TO 3 DRIVER DISTRACTED OFFENSE CHARGED LOCAL CODE / DRUG SUSPECTED OTHER DRUG MARIJUANA OFFENSE DESCRIPTION CONDITION 2/23/ STATUS TEST TYPE. VALUE AIR BAG USAGE 3 EJECTION CITATION NUMBER STATUS DRUG TEST(S) M TRAPPED TYPE RESULTS SELECT UP TO UNIT # DATE OF BIRTH AGE GENDER OL STATE EMS AGENCY (NAME) INJURED TO: MEDICAL FACILITY (NAME, CITY) SAFETY EQUIPMENT OPERATOR LICENSE NUMBER OFFENSE CHARGED LOCAL CODE ENDORSEMENT RESTRICTION SELECT UP TO 3 DRIVER DISTRACTED / DRUG SUSPECTED OTHER DRUG MARIJUANA OFFENSE DESCRIPTION CITATION NUMBER CONDITION TEST DRUG TEST(S) STATUS TYPE VALUE. STATUS TYPE RESULTS SELECT UP TO UNIT # DATE OF BIRTH AGE GENDER OL STATE - FATAL INJURIES 2 - SUSPECTED SERIOUS INJURY 3 - SUSPECTED MINOR INJURY - POSSIBLE INJURY 5 - NO APPARENT INJURY - NOT TRANSPORTED /TREATED AT SCENE 2 - EMS 3 - POLICE - NONE 2 - SHOULDER BELT ONLY 3 - LAP BELT ONLY - SHOULDER & LAP BELT 5 - CHILD RESTRAINT SYSTEM - FORWARD FACING 6 - CHILD RESTRAINT SYSTEM - REAR FACING 7 - BOOSTER SEAT 8 - HELMET 9 - PROTECTIVE PADS (ELBOWS, KNEES, ETC) 0 - REFLECTIVE CLOTHING - LIGHTING - PEDESTRIAN / BICYCLE ONLY EMS AGENCY (NAME) INJURED TO: MEDICAL FACILITY (NAME, CITY) SAFETY EQUIPMENT OPERATOR LICENSE NUMBER OFFENSE CHARGED LOCAL CODE INJURIES SAFETY EQUIPMENT ENDORSEMENT RESTRICTION SELECT UP TO 3 DRIVER DISTRACTED - FRONT - LEFT SIDE (MOTORCYCLE DRIVER) 2 - FRONT - MIDDLE 3 - FRONT - RIGHT SIDE - SECOND - LEFT SIDE (MOTORCYCLE PASSENGER) 5 - SECOND - MIDDLE 6 - SECOND - RIGHT SIDE 7 - THIRD - LEFT SIDE (MOTORCYCLE SIDE CAR) 8 - THIRD - MIDDLE 9 - THIRD - RIGHT SIDE 0 - SLEEPER SECTION OF TRUCK CAB - PASSENGER IN OTHER ENCLOSED CARGO AREA (NON-TRAILING UNIT, BUS, PICK-UP WITH CAP) 2 - PASSENGER IN UNENCLOSED CARGO AREA 3 - TRAILING UNIT - RIDING ON EXTERIOR (NON-TRAILING UNIT) 5 - NON-MOTORIST AIR BAG / DRUG SUSPECTED - NOT DEPLOYED 2 - DEPLOYED FRONT 3 - DEPLOYED SIDE - DEPLOYED BOTH FRONT/SIDE 5 - NOT APPLICABLE 9 - DEPLOYMENT UNKNOWN EJECTION - NOT EJECTED 2 - PARTIALLY EJECTED 3 - TOTALLY EJECTED - NOT APPLICABLE TRAPPED - NOT TRAPPED 2 - EXTRICATED MECHANICAL MEANS 3 - FREED NON-MECHANICAL MEANS OTHER DRUG MARIJUANA OFFENSE DESCRIPTION CITATION NUMBER CONDITION TEST DRUG TEST(S) OL RESTRICTION(S) STATUS TYPE VALUE. DRIVER DISTRACTION - CLASS A - INTERLOCK - NOT DISTRACTED DEVICE 2 - MANUALLY OPERATING AN 2 - CLASS B 2 - CDL INTRASTATE ONLY ELECTRONIC 3 - CLASS C 3 - CORRECTIVE LENSES COMMUNICATION DEVICE - FARM WAIVER (TEXTING, TYPING, - REGULAR CLASS 5 - EXCEPT CLASS A BUS DIALING) (OHIO = D) 6 - EXCEPT CLASS A 3 - TALKING ON HANDS-FREE & CLASS B BUS COMMUNICATION DEVICE 5 - M/C MOPED ONLY 7 - EXCEPT TRACTOR-TRAILER - TALKING ON HAND-HELD 6 - NO VALID OL 8 - INTERMEDIATE LICENSE COMMUNICATION DEVICE RESTRICTIONS 5 - OTHER ACTIVITY WITH AN 9 - LEARNER'S PERMIT ELECTRONIC DEVICE OL ENDORSEMENT RESTRICTIONS 6 - PASSENGER 0 - LIMITED TO DAYLIGHT 7 - OTHER DISTRACTION H - HAZMAT ONLY INSIDE THE M - MOTORCYCLE - LIMITED TO EMPLOYMENT 8 - OTHER DISTRACTION P - PASSENGER 2 - LIMITED - OTHER OUTSIDE THE 3 - MECHANICAL DEVICES N - TANKER (SPECIAL BRAKES, HAND CONDITION Q - MOTOR SCOOTER CONTROLS, OR OTHER ADAPTIVE DEVICES) - APPARENTLY NORMAL R - THREE-WHEEL - MILITARY S ONLY 2 - PHYSICAL IMPAIRMENT MOTORCYCLE 5 - MOTOR S 3 - EMOTIONAL (E.G., S - SCHOOL BUS WITHOUT AIR BRAKES DEPRESSED, ANGRY, 6 - OUTSIDE MIRROR DISTURBED) T - DOUBLE & TRIPLE 7 - PROSTHETIC AID TRAILERS - ILLNESS 8 - OTHER 5 - FELL ASLEEP, FAINTED, X - TANKER / HAZMAT FATIGUED, ETC. 6 - UNDER THE INFLUENCE OF GENDER MEDICATIONS / DRUGS / F - FEMALE M - MALE U - OTHER / UNKNOWN STATUS TYPE RESULTS SELECT UP TO TEST STATUS - NONE GIVEN 2 - TEST REF 3 - TEST GIVEN, CONTAMINATED SAMPLE / UNUSABLE - TEST GIVEN, RESULTS KNOWN 5 - TEST GIVEN, RESULTS UNKNOWN TEST TYPE - NONE 2 - BLOOD 3 - URINE - BREATH 5 - OTHER DRUG TEST TYPE - NONE 2 - BLOOD 3 - URINE - OTHER DRUG TEST RESULT(S) - AMPHETAMINES 2 - BARBITURATES 3 - BENZODIAZEPINES - CANNABINOIDS 5 - COCAINE 6 - OPIATES / OPIOIDS 7 - OTHER 8 - NEGATIVE RESULTS PAGE 3 OF

4 / WITNESS ADDENDUM UNIT # DATE OF BIRTH AGE GENDER EMS AGENCY (NAME) INJURED TO: MEDICAL FACILITY (NAME, CITY) SAFETY EQUIPMENT UNIT # DATE OF BIRTH AGE GENDER EMS AGENCY (NAME) INJURED TO: MEDICAL FACILITY (NAME, CITY) SAFETY EQUIPMENT UNIT # DATE OF BIRTH AGE GENDER EMS AGENCY (NAME) INJURED TO: MEDICAL FACILITY (NAME, CITY) SAFETY EQUIPMENT UNIT # DATE OF BIRTH AGE GENDER EMS AGENCY (NAME) INJURED TO: MEDICAL FACILITY (NAME, CITY) SAFETY EQUIPMENT INJURIES - FATAL 2 - SUSPECTED SERIOUS INJURY 3 - SUSPECTED MINOR INJURY - POSSIBLE INJURY 5 - NO APPARENT INJURY INJURED - NOT TRANSPORTED / TREATED AT SCENE 2 - EMS 3 - POLICE SAFETY EQUIPMENT AIR BAG USAGE - NONE SHOULDER BELT ONLY 3 - LAP BELT ONLY - SHOULDER & LAP BELT 5 - CHILD RESTRAINT SYSTEM - FORWARD FACING 6 - CHILD RESTRAINT SYSTEM - REAR FACING 7 - BOOSTER SEAT 8 - HELMET 9 - PROTECTIVE PADS (ELBOWS, KNEES, ETC) 0 - REFLECTIVE CLOTHING - LIGHTING - PEDESTRIAN / BICYCLE ONLY - FRONT - LEFT SIDE (MOTORCYCLE DRIVER) 2 - FRONT - MIDDLE 3 - FRONT - RIGHT SIDE - SECOND - LEFT SIDE (MOTORCYCLE PASSENGER) 5 - SECOND - MIDDLE 6 - SECOND - RIGHT SIDE 7 - THIRD - LEFT SIDE (MOTORCYCLE SIDE CAR) 8 - THIRD - MIDDLE 9 - THIRD - RIGHT SIDE 0 - SLEEPER SECTION OF TRUCK CAB - PASSENGER IN OTHER ENCLOSED CARGO AREA (NON-TRAILING UNIT SUCH AS A BUS, PICK-UP WITH CAP) 2 - PASSENGER IN UNENCLOSED CARGO AREA 3 - TRAILING UNIT - RIDING ON EXTERIOR (NON-TRAILING UNIT) 5 - NON-MOTORIST - NOT DEPLOYED 2 - DEPLOYED FRONT 3 - DEPLOYED SIDE - DEPLOYED BOTH FRONT/SIDE 5 - NOT APPLICABLE 9 - DEPLOYMENT UNKNOWN - NOT EJECTED 2 - PARTIALLY EJECTED 3 - TOTALLY EJECTED - NOT APPLICABLE - NOT TRAPPED EJECTION TRAPPED 2 - EXTRICATED MECHANICAL MEANS 3 - FREED NON-MECHANICAL MEANS DATE OF BIRTH AGE GENDER WITNESS DATE OF BIRTH AGE GENDER WITNESS DATE OF BIRTH AGE GENDER WITNESS PAGE OF

5 OHIO TRAFFIC ACCIDENT - OH2 NARRATIVE IN COUNTY OF Warren County REPORTING AGENCY Hamilton Township ACCIDENT LOCATION DATE OF CRASH 03/2/209 OFFICERS SIGNATURE BADGE NO.

6 OHIO TRAFFIC ACCIDENT - OH2 DIAGRAM IN COUNTY OF Warren County REPORTING AGENCY Hamilton Township ACCIDENT LOCATION Date Of Crash 03/2/209 OFFICERS SIGNATURE BADGE NO.