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, -07 WAS DOT PROPERTY INVOLVED IN THIS CRASH? TOTAL # OF VEHICLE SECTION(S) TOTAL # OF PERSON SECTION(S) TOTAL # OF NARRATIVE SECTION(S) CRASH DATE 0/0/07 CRASH IDENTIFIERS COUNTY CODE WITNESSES KYLE Light Condition Daylight Dusk Dawn 4 Dark-Lighted First Harmful Event 4 First Harmful Event within Interchange No Non-Junction Intersection Intersection-Related 4 Driveway/Alley Access Related Work Zone Related CITY CODE 0 NAME Dark-Not Lighted 6 Dark-Unknown Lighting Weather Condition 4 Flog, Smog, Smoke Sleet/Hail/ Freezing Rain 6 Blowing Sand, Soil Dirt Clear 7 Severe Crosswinds Cloudy Rain Non-Collision Overturn/Rollover Fire/Explosion Immersion 4 Jackknife Cargo/Equipment Loss or Shift 6 Fell/Jumped From Motor Vehicle 7 Thrown or Falling Object 8 Ran int Water/Canal Other Collision First Harmful Event Relation to No TIME OF CRASH 4:0 PM COUNTY OF CRASH LEON CRASH INFORMATION (CHECK IF PICTURES TAKEN) DATE OF REPORT 0/0/07 TIME ON SCENE TIME CLEARED SCENE CHECK IF 4:8 PM :0 PM COMPLETED ROADWAY INFORMATION (CHOOSE ONLY OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAY E 6TH AVE AT FEET MILES N S E W 64 Interstate U.S. State Road System Identifier 4 County Local 6 Turnpike/Toll Roadway Surface Condition Oil 6 Mud, Dirt, Gravel 7 Sand 8 Water (standing/moving) Dry Wet 4 Ice/Frost Collision Non-Fixed Object 0 Pedestrian Impact Attenuator/Crash Pedalcycle Cusion Railway vehicle (train, 0 Bridge Overhead Structure engine) Bridge Pier or Support Animal Bridge Rail 4 Motor Vehicle in Culvert Transport 4 Curb Parked Motor Vehicle Ditch 6 Work Zone/Maintainance 6 Embankment Equipment 7 Guardrail Face 7 Struck By Falling, Shifting 8 Guardrail End Cargo Cable Barrier 8 Other Non-Fixed Object Contributing Circumstances: Road Junction Railway Grade Crossing 4 Entrance/Exit Ramp Crossover - Related None 6 Shared-Use of Path or Trail 7 Acceleration/Dceleration Lane 4 Work Zone (construction/ 8 Through Roadway maintenance/utility 6 Shoulders (none, low, soft, high) 7 Rut, Holes, Bumps Crash in Work Zone Before the First Work Zone Warning Sign Advance Warning Area Transition Area 4 Activity Area Termination Area 7 Forest Road 8 Private Roadway Parking Lot REPORTING AGENCY CASE NUMBER PLACE OR CITY OF CRASH TALLAHASSEE REASON (If Investigation NOT Complete) AT STREET ADDRESS # AT/FROM INTERSECTION WITH STREET, ROAD,HIGHWAY N MONROE ST Type of Work Zone Lane Closure Lane Shift/Crossover Work on Shoulder or Median 4 Intermittent or Moving Work ADDRESS DARRELL VAUGHN 0 GLEN EAGLE WAY Type of Shoulder Paved Unpaved Curb School Bus Related CITY & TALLAHASSEE ZIP CODE NAME ADDRESS CITY & ZIP CODE No, School Bus Directly Involved Yes, School Bus Indirectly Involved Collision with Fixed Object 0 Concrete Other Traffic Barrier Tree (standing) Utility Pole/Light Support 4 Traffic Sign Support Traffic Signal Support 6 Ohter Post, Pole or Support 7 Fence 8 Mailbox Other Fixed Object (wall, building, tunnel, etc.) Worn, Travel-Polished Surface 0 Raod Surface Condition (wet, icy, snow, slush, etc.) Obstruction in Roadway Debris Traffic Control Device Inoperative, Missing or Obscured 4 Non-Highway Work HSMV CRASH REPORT NUMBER CHECK IF WITHIN CITY LIMITS AT LATITUDE Type of Intersection Not at Intersection Four-Way Intersection T-Intersection 4 Y-Intersection Workers in Work Zone No TIME REPORTED Front to Rear Front to Front Angle 4:4 PM Manner of Collision/Impact 4 Sideswipe, same direction Sideswipe, Opposite Direction 6 Rear to Side 7 Rear to Rear First Harmful Event Location On Roadway Off Roadway Shoulder 4 Median 6 Gore 7 Separator 8 In Parking Lane or Zone Outside Right-of-way 0 Roadside Contributing Circumstances: Environment None Weather Conditions Physical Obstruction(s) 4 Glare TIME DISPATCHED 4: PM Notified By: Motorist Law Enforcement AND LONGITUDE OR FROM MILEPOST # 4 Traffic Circle 6 Roundabout 7 Five-Point, or More Animal(s) in Roadway Law Enforcement in Work Zone No Officer Present Law Enforcement Vehicle Only Present NAME ADDRESS CITY & ZIP CODE NON VEHICLE PROPERTY DAMAGE VEH. # PER # PROPERTY DAMAGE - OTHER THAN VEH. EST. AMT. OWNER'S NAME (CHECK IF BUSINESS) ADDRESS CITY & ZIP CODE VEH. # PER # PROPERTY DAMAGE - OTHER THAN VEH. EST. AMT. OWNER'S NAME (CHECK IF BUSINESS) ADDRESS CITY & ZIP CODE HSMV 000 S

2 VEHICLE # Vehicle in Transport VEHICLE LICENSE NUMBER Parked Motor Vehicle Working Vehicle YK Hit and Run No SELF-INSURED YEAR 06 INSURANCE COMPANY (DRIVER) Check if Commercial MAKE CHEV MODEL TAHOE INSURANCE POLICY NUMBER REGISTRATION EXPIRES NAME OF VEHICLE OWNER (CHECK IF BUSINESS) CURRENT ADDRESS DEPARTMENT OF THE PLAZA LEVEL FINANCIAL SERVICES Trailer LICENSE NUMBER REGISTRATION EXPIRES Check if Permanent One: STYLE SUV Check if Permanent COLOR BLUE - BLU VIN GNLCDKCGR74 Towed due VEHICLE REMOVED BY to Damage: No DRIVER CITY & TALLAHASSEE DAMAGE: EST. AMOUNT Disabling 4 Minor Functional None $, Rotation. Owner Request. Driver 4. Other, Explain in ZIP 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 MOTOR CARRIER NAME N S E W Off-Road Unknown HAZ. MAT. PLACARD No NUMBER ON STREET, ROAD, HIGHWAY 6TH AVE US DOT NUMBER CLASS Area of Initial Impact AT EST. SPEED 0 POSTED SPEED 8 Undercarriage 8 Overturn 0 Windshield 0 Trailer TOTAL LANES Most Damaged Area MOTOR CARRIER ADDRESS CITY ZIP CODE PHONE NUMBER Vehicle Body Type 6 Passenger Car Passenger Van Pickup 7 Motor Home 8 Bus Motorcycle Moped All Terrain Vehicle (ATV) Most Harmful Event Sequence of Events st 4 rd VIOLATIONS PERSON # 4 Low Speed Vehicle 6 (Sport) Utility Vehicle 7 Cargo Van (0,000 lbs (4,6 kg) or less) 8 Motor Coach Other Light Trucks (0,000 lbs (4,6 kg) or less) 0 Medium/Heavy Trucks (more than 0,000 lbs (4,6 kg)) Farm Labor Vehicle Interstate Carrier Intrastate Carrier Not in Commerce/Government 4 Not in Commerce/Other Truck Non-Collision Overturn/Rollover Fire/Explosion Immersion 4 Jackknife Cargo/Equipment Loss or Shift 6 Fell/Jumped From Motor Vehicle 7 Thrown or Falling Object 8 Ran into Water/Canal Other Non-Collision [40-46 Sequence of Events only] 40 equipment Failure (blown tire, brake failure, etc.) 4 Separation of Units 4 Ran Off Roadway, Right 4 Ran Off Roadway, Left 44 Cross Median 4 Cross Centerline 46 Downhill Runaway Trafficway Two-Way, Not Divided Two-Way, Not Divided, with a Continuous Left Turn Lane Two-Way, Divided, Unprotected (painted >4 feet) Median 4 Two-Way, Divided, Positive Median Barrier One-Way Trafficway Comm/Non-Commercial TRAILER TRAILER nd 4th Roadway Grade Level Hillcrest Uphill 4 Downhill Sag (bottom) Special Function of Motor Vehicle JIMMY Roadway Alignment NAME OF VIOLATOR T Straight Curve Right Curve Left No Special Function Farm Vehicle Police 7 Taxi 8 Military PATRONIS Comm GVWR/GCWR Single Semi Trailer Tandem Semi Trailer Tank Trailer 4 Saddle Mount/Trailer Boat Trailer 6 Utility Trailer 7 House Trailer 4 Commercial Motor Vehicle Configuration Vehicle 0,000 lbs or less Placarded 8 Tractor/Triple for Hazardous Materials Truck more than 0,000 lbs (4,6 Single-Unit Truck (-axle and GVWR kg), Cannot Classify more than 0,000 lbs (4,6 kg)) 0 Bus/Large van (seats for - occupants, including driver) Single-Unit Truck ( or more axles) 4 Truck Pulling Trailer(s) Truck Tractor (bobtail) 6 Truck Tractor/Semi-Trailer 7 Truck Tractor/Double Truck 0,000 lbs (4,6 kg) or less 0,00-6,000 lbs (4,6-,7kg) More than 6,000 lbs (,7kg) 4 Not Applicable Collision with Non-Fixed Object 0 Pedestrian Pedalcycle Railway Vehicle (train, engine) Animal 4 Motor Vehicle in Transport Parked Motor Vehicle 6 Work Zone/Maintenance Equipment 7 Struck By Falling, Shifting Cargo or Anything Set in Motion by Motor Vehicle 8 Other Non-Fixed Object Vehicle Maneuver Action Straight Ahead Stopped in Traffic Turning Left 4 Slowing 4 Backing Negotiating a Curve Turning Right 6 Leaving Traffic Lane 6 Changing Lanes 7 Entering Traffic Lane 8 Parked 0 Making U-Turn Overtaking/Passing Ambulance 0 Fire Truck Farm Labor Transport School Bus Transit/Commuter Bus J 6.()(B) Trailer Type 4 Intercity Bus Charter/Tour Bus 6 Shuttle Bus 7 Farm Labor Bus STATUTE NUMBER No Controls 4 School Zone Sign/ Device Traffic Control Signal 6 Stop Sign 7 Yield Sign This Vehicle 8 Flashing Signal Railway Crossing Device 0 Person (including Flagman, Officer, Guard, etc.) Bus (seats for more than occupants, including driver) 8 Pole Trailer Towed Vehicle Cargo Body Type Intermodal 0 Auto Transport Van/Enclosed Box Container Chassis 4 Hopper 4 Vehicle Towing Pole-Trailer Another Vehicle 6 Cargo Tank Not Applicable No Cargo 7 Flatbed (vehicle 0,000 lbs Bus 8 Dump (4,6 kg) or less not Concrete Mixer displaying HM placard 0 Auto Transport Garbage/Refuse Collision Fixed Object Log Cable Barrier Emergency Impact Attenuator/Crash Cushion 0 Concrete Traffic Barrier Vehicle Use 0 Bridge Overhead Structure Other Traffic Barrier Bridge Pier or Support Tree (standing) Bridge Rail Utility Pole/Light Support Culvert 4 Traffic Sign Support 4 Curb Traffic Signal Support No Ditch 6 Other Post, Pole, or Support 6 Embankment 7 Fence 7 Guardrail Face 8 Mailbox 8 Guardrail End Other Fixed Object (wall, building, tunnel, etc.) Traffic Control Device For Vehicle Defects IMPROPER LEFT TURN CHARGE None Brakes Wheels Tires 4 Windows/ 4 Lights (head, Windshield signal, tail) Mirrors 6 Steering 6 Truck Coupling 7 Wipers Trailer Hitch/ Exhaust System Safety Chains 0 Body, Doors Power Train Suspension CITATION NUMBER A66KE HSMV 000 S

3 PERSON # Driver VEHICLE # Non-Motorist Passenger CURRENT ADDRESS (Number and Street) NAME JIMMY T PATRONIS CITY & J PHONE NUMBER (80) ZIP CODE Check if Recommend Driver Re-exam 877 N LAGOON DR. DATE OF BIRTH 4//7 DL Type A B C 4 D/Chauffeur E/Operator 6 E/Oper-Rest 7 None Driver Distracted By Not Distracted Electronic Communication Devices (cell phone, etc. Other Electronic Device (navigation device, DVD player) DRIVER VISION OBSTRUCTIONS Vision Not Obscured Inclement Weather Parked/Stopped Vehicle 4 Trees/Crops/Bushes Motor Vehicle Seating Position: Seat Left Midde Right 77 Other (explain in narrative) SEX: DRIVERS LICENSE NUMBER Male Female P64870 Required Endorsements Yes No No Req. Endorsement 4 Other Inside the Vehicle (explain in narrative) External Distraction (outside the vehicle, explain in narrative) 6 Texting 7 Inattentive Load on Vehicle 6 Building/Fixed Object 7 Signs/Billboards 8 Fog Non-Motorist Description Pedestrian Other Pedestrian (wheelchari, person in a building, skater, pedestrian conveyance, etc. Bicyclist 4 Other Cyclist Occupant of Motor Vehicle Not in Transport (parked, etc.) 6 Occupant of a Non-Motor Vehicle Transportation Device 7 Unknown Type of Non-Motorist SUSPECTED ALCOHOL USE: No Row Front Second Third 4 Fourth 77 Other Row None Safety Equipment Helmet Protective Pads Used (elbows, knees, shins, etc.) 4 Reflective Clothing (jacket, backpack, etc.) DRIVER OR PASSENGER Other Lighting 6 Not Applicable 77 Other, Explain in ALCOHOL TESTED: Test Not Given Test Refused Test Given, if Tested LOCATION: (LOC) Smoke 0 Glare 77 All Other, Explain in st 6 nd PANAMA CITY DRIVER Drivers Actions No Contribution Action Operated MV in Carelss or Negligent Manner Failed to Yield Right-of-Way 4 Improper Backing 6 Improper Turn 0 Followed too Closely Ran Red Light Drove too Fast for Conditions Ran Stop Sign Improper Passing 7 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 4 Not Applicable NON-MOTORIST Non-Motorist Location At Time of Crash Intersection - Marked Crosswalk Intersection - Unmarked Crosswalk Intersection - Other4 Midblock - Marked Crosswalk 4 Midblock - Marked Crosswalk Travel Lane - Other Location 6 Bicycle Lane 7 shoulder/roadside st nd SEAT ROW Not Applicable Sleeper Section of Truck Cab Other Enclosed Cargo Area 4 Unenclosed Cargo Area Trailing Unit 6 Riding on Motor Vehicle Exterior (nontrailing unit) ALCOHOL TEST TYPE: Blood Breath Urine 77 Other, Explain in OTHER Non-Motorist Actions/Circumstances No Improper Action Dart/Dash Failure to Yield Right-of-Way 4 Failure to Obey Traffic Signs Signals, or Officer In Roadway Improperly (standing, lying, working, playing) 6 Disabled Vehicle Related (working on, pushing, leaving/approaching) ALCOHOL TEST RESULT: PENDING COMPLETED 88 UNKNOWN DOT-Compliant Motorcycle Helmet Other Helmet No Helmet EXPIRES 4//00 at Time of Crash 6 Ran off Roadway 7 Disregarded other Traffic Sign 8 Disregarded Other Road Markings 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 77 Other Contributing Action 408 INJURY SEVERITY (INJ) None 4 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 4 Deployed-Side 7 Deployed-Curtain 88 Deployment Unknown 8 Sidewalk Median/Crossing Island 0 Driveway Access Shared-Use Path or Trail Non-Trafficway Area 7 Entering/Exiting Parked/Standing Vehicle 8 Inattentive (talking, eating, etc) Not Visible (dark clothing, no lighting, etc.) ALCOHOL/DRUG/EMS BAC SUSPECTED DRUG USE: No rd 4th DRIVER OR PASSENGER Action Prior to Crash Crossing Roadway Waiting to Cross Roadway Walking/Cycling Along Roadway with Traffic (in or adjacent to travel lane) 4 Walking/Cycling Along Roadway Against Traffic (in or adjacent to travel lane) Condition At Time of Apparently Normal Asleep or Fatiuged Ill (sick) or Fainted 6 Seizure, Epilespsy, Blackout 7 Physically Impaired 8 Emotional (depression, angry, disturbed, etc.) Under the Influence of Medications/Drugs/Alcohol Restraint Systems (RS) Not Applicable (non-motorist) None Used - Motor Vehicle Occupant Shoulder and Lap Belt Used 4 Shoulder Belt Only Used Lap Belt Only Used 6 Restraint Used - Type Unknown 7 Child Restraint System - Forward Facing 8 Child Restraint System - Rear Facing 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.) 7 Adjacent to Raodway (e.g., shoulder, median) 8 Going to or from School (K-) Working in Trafficway (incident response) 0 None DRUG TEST TYPE: DRUG TEST RESULT: Blood Positive Urine Negative 77 Other, Pending Explain in Not Transported EMS Law Enforcement Not Transported EMS Law Enforcement Not Transported EMS Law Enforcement HSMV 000 S

4 NARRATIVE V- was traveling east on 6th Ave, in 00 block while occupying the left lane, approaching the intersection of Thomasville Rd. V- was traveling east on 6th Ave, in the 00 block while occupying the right lane, approaching the intersection of Thomasville Rd. Witness- was directly behind V-. D- stated that she was operating V-. D- stated that she was heading east on 6th and observed V- just ahead of her in the right lane. D- stated that while driving, she saw V- suddenly attempt to make a left turn across her lane without signaling. D- stated that she was unable to stop in time to avoid contact and struck V-. V- front left bumper and hood struck V- left front and rear door. Not Transported EMS Law Enforcement Not Transported EMS Law Enforcement ADDITIONAL VIOLATIONS REPORTING OFFICER ID/BADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. 66 PATROL EDWARDS TALLAHASSEE POLICE DEPARTM POLICE DEPARTMENT HSMV 000 S 4

5 DIAGRAM REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER HSMV 000 S

6 VEHICLE # Vehicle in Transport Parked Motor Vehicle Working Vehicle Hit and Run No YEAR 00 INSURANCE COMPANY (DRIVER) UNITED SERVICES AUTOMOB LOWELL THOMAS DAVIS VEHICLE LICENSE NUMBER 884QD MAKE NISS NAME OF VEHICLE OWNER (CHECK IF BUSINESS) Check if Commercial MODEL MURANO INSURANCE POLICY NUMBER 0867U704 CURRENT ADDRESS REGISTRATION EXPIRES 06//08 0 BEAVER CREEK DR STYLE UTILITY Towed due to Damage: No Check if Permanent COLOR BLACK - BLK VIN JN8AZMU0AW048 DAMAGE: Disabling Functional None VEHICLE REMOVED BY UNKNOWN AT THS TIM CITY & HAVANA EST. AMOUNT 4 Minor $0, Rotation. Owner Request. Driver 4. Other, Explain in ZIP Trailer One: Trailer Two: LICENSE NUMBER REGISTRATION EXPIRES LICENSE NUMBER REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES Check if Permanent VIN YEAR MAKE LENGTH AXLES VEHICLE TRAVELING N HAZ. MAT. RELEASED No MOTOR CARRIER NAME S E W Off-Road Unknown ON STREET, ROAD, HIGHWAY 6TH AVE HAZ. MAT. PLACARD NUMBER CLASS No US DOT NUMBER Area of Initial Impact AT EST. SPEED POSTED SPEED Undercarriage 8 Overturn 0 Windshield 0 Trailer TOTAL LANES Most Damaged Area MOTOR CARRIER ADDRESS CITY ZIP CODE PHONE NUMBER Vehicle Body Type 6 Passenger Car Passenger Van Pickup 7 Motor Home 8 Bus Motorcycle Moped All Terrain Vehicle (ATV) Most Harmful Event Low Speed Vehicle 6 (Sport) Utility Vehicle 7 Cargo Van (0,000 lbs (4,6 kg) or less) 8 Motor Coach Other Light Trucks (0,000 lbs (4,6 kg) or less) 0 Medium/Heavy Trucks (more than 0,000 lbs (4,6 kg)) Farm Labor Vehicle Comm/Non-Commercial Interstate Carrier Intrastate Carrier Not in Commerce/Government 4 Not in Commerce/Other Truck Non-Collision Overturn/Rollover Fire/Explosion Immersion 4 Jackknife Cargo/Equipment Loss or Shift 6 Fell/Jumped From Motor Vehicle 7 Thrown or Falling Object 8 Ran into Water/Canal Other Non-Collision Trafficway Two-Way, Not Divided Two-Way, Not Divided, with a Continuous Left Turn Lane Two-Way, Divided, Unprotected (painted >4 feet) Median 4 Two-Way, Divided, Positive Median Barrier One-Way Trafficway TRAILER TRAILER Comm GVWR/GCWR Trailer Type Single Semi Trailer Tandem Semi Trailer Tank Trailer 4 Saddle Mount/Trailer Boat Trailer 6 Utility Trailer 7 House Trailer 4 Commercial Motor Vehicle Configuration Vehicle 0,000 lbs or less Placarded 8 Tractor/Triple for Hazardous Materials Truck more than 0,000 lbs (4,6 Single-Unit Truck (-axle and GVWR kg), Cannot Classify more than 0,000 lbs (4,6 kg)) 0 Bus/Large van (seats for - Single-Unit Truck ( or more axles) occupants, including driver) 4 Truck Pulling Trailer(s) Bus (seats for more than Truck Tractor (bobtail) occupants, including driver) 6 Truck Tractor/Semi-Trailer 7 Truck Tractor/Double Truck 8 Pole Trailer Towed Vehicle 0 Auto Transport 0,000 lbs (4,6 kg) or less 0,00-6,000 lbs (4,6-,7kg) More than 6,000 lbs (,7kg) 4 Not Applicable No Cargo Bus Cargo Body Type Van/Enclosed Box 4 Hopper Pole-Trailer 6 Cargo Tank 7 Flatbed 8 Dump Concrete Mixer 0 Auto Transport Garbage/Refuse Log Intermodal Container Chassis 4 Vehicle Towing Another Vehicle Not Applicable (vehicle 0,000 lbs (4,6 kg) or less not displaying HM placard Collision with Non-Fixed Object Collision Fixed Object 0 Pedestrian Cable Barrier 4 Impact Attenuator/Crash Cushion Pedalcycle 0 Concrete Traffic Barrier 0 Bridge Overhead Structure Railway Vehicle (train, engine) Other Traffic Barrier Bridge Pier or Support Sequence of Events Animal Tree (standing) Bridge Rail 4 Motor Vehicle in Transport Utility Pole/Light Support Culvert st nd Parked Motor Vehicle 4 Traffic Sign Support [40-46 Sequence of Events only] 6 Work Zone/Maintenance 4 Curb Traffic Signal Support 4 40 equipment Failure (blown tire, Equipment Ditch 6 Other Post, Pole, or Support brake failure, etc.) 7 Struck By Falling, Shifting Cargo or 6 Embankment 7 Fence rd 4th 4 Separation of Units Anything Set in Motion by Motor 7 Guardrail Face 8 Mailbox 4 Ran Off Roadway, Right Vehicle 8 Guardrail End Other Fixed Object (wall, 4 Ran Off Roadway, Left 8 Other Non-Fixed Object building, tunnel, etc.) 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 4 Cross Centerline Straight Ahead Stopped in Traffic This Vehicle Roadway Grade 46 Downhill Runaway Turning Left 4 Slowing 4 Backing Negotiating a Curve Level 8 Flashing Signal None Hillcrest Turning Right 6 Leaving Traffic Lane Railway Crossing Roadway Alignment No Controls Brakes Uphill 6 Changing Lanes 7 Entering Traffic Lane Device 4 School Zone Sign/ Tires 4 Downhill Straight 8 Parked 0 Person (including Device 4 Lights (head, Sag (bottom) Curve Right 0 Making U-Turn Flagman, Officer, Traffic Control signal, tail) Curve Left Overtaking/Passing Guard, etc.) Signal 6 Steering Special Function No Special Function Ambulance 4 Intercity Bus 6 Stop Sign 7 Wipers Farm Vehicle 0 Fire Truck Charter/Tour Bus 7 Yield Sign Exhaust System of Motor Vehicle Police Farm Labor Transport 6 Shuttle Bus 0 Body, Doors 7 Taxi School Bus 7 Farm Labor Bus Power Train 8 Military Transit/Commuter Bus Suspension VIOLATIONS Emergency Vehicle Use No Wheels 4 Windows/ Windshield Mirrors 6 Truck Coupling Trailer Hitch/ Safety Chains HSMV 000 S 6

7 NARRATIVE D- stated that he was driving V-. D- stated that he was in the right lane at the time and as he drove east passing the business at 4 E 6th Ave. D- stated that he wanted to turn into the business and admitted that he did not check to see if the left lane was clear before attempting to cross over. D- stated that as he started to turn, his V- was struck by V-. V- left front and rear doors were struck by V- front right bumper and hood. Witness- stated that he was directly behind V-. W- stated that he saw V- attempt to make an illegal left turn without signaling and turned directly in front of V-. W- stated that V- was unable to avoid hitting V-. D- did not complain of any injuries and declined EMS. Not Transported EMS Law Enforcement Not Transported EMS Law Enforcement ADDITIONAL VIOLATIONS REPORTING OFFICER ID/BADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. 66 PATROL EDWARDS TALLAHASSEE POLICE DEPARTM POLICE DEPARTMENT HSMV 000 S 7

8 NARRATIVE D- did not complain of any injuries and declined EMS V- sustained functional damage to the left front and rear doors. V- did not need to be towed and was driven from the scene by D-. V- airbags did not deploy. V- sustained disabling damage to the front right bumper and hood. V- had to be towed from the scene at D- request and D- contacted their own towing company to respond. The name of the towing company was not relayed to this officer prior to me departing the scene. V- airbags did not deploy. Due to V- being a state owned Vehicle, Deputy Chief Financial Officer Jay Etheridge arrived on scene and took photos of V-. Etheridge also notified risk management while on scene. After speaking with all parties, D- was found to be at fault for the traffic crash. D- was issued a citation. Not Transported EMS Law Enforcement Not Transported EMS Law Enforcement ADDITIONAL VIOLATIONS REPORTING OFFICER ID/BADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. 66 PATROL EDWARDS TALLAHASSEE POLICE DEPARTM POLICE DEPARTMENT HSMV 000 S 8

9 PERSON # Driver Non-Motorist Passenger VEHICLE # CURRENT ADDRESS (Number and Street) NAME SARAH KATHLEEN DAVIS CITY & PHONE NUMBER (04) 70- ZIP CODE Check if Recommend Driver Re-exam 60 INGLESIDE AVE DATE OF BIRTH 7/8/ DL Type A B C 4 D/Chauffeur E/Operator 6 E/Oper-Rest 7 None Driver Distracted By SEX: Male Female Not Distracted Electronic Communication Devices (cell phone, etc. Other Electronic Device (navigation device, DVD player) DRIVER VISION OBSTRUCTIONS Vision Not Obscured Inclement Weather Parked/Stopped Vehicle 4 Trees/Crops/Bushes Motor Vehicle Seating Position: Seat Row Other Left Midde Right 77 Other (explain in narrative) Non-Motorist Description Pedestrian Other Pedestrian (wheelchari, person in a building, skater, pedestrian conveyance, etc. Bicyclist 4 Other Cyclist Occupant of Motor Vehicle Not in Transport (parked, etc.) 6 Occupant of a Non-Motor Vehicle Transportation Device 7 Unknown Type of Non-Motorist SUSPECTED ALCOHOL USE: No Front Second Third 4 Fourth 77 Other Row Required Endorsements Yes No No Req. Endorsement DRIVERS LICENSE NUMBER D Other Inside the Vehicle (explain in narrative) External Distraction (outside the vehicle, explain in narrative) 6 Texting 7 Inattentive st nd TALLAHASSEE No Contribution Action Operated MV in Carelss or Negligent Manner Failed to Yield Right-of-Way 4 Improper Backing 6 Improper Turn 0 Followed too Closely Ran Red Light Drove too Fast for Conditions Ran Stop Sign Improper Passing 7 Exceeded Posted Speed Wrong Side of Wrong Way Failed to Keep in Proper Lane Load on Vehicle Smoke 6 Building/Fixed Object 0 Glare 7 Signs/Billboards 8 Fog 77 All Other, Explain in Helmet Use DRIVER OR PASSENGER None Safety Equipment Lighting Helmet 6 Not Applicable Protective Pads Used 77 Other, Explain (elbows, knees, shins, etc.) in 4 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 4 Not Applicable NON-MOTORIST Non-Motorist Location At Time of Crash Intersection - Marked Crosswalk Intersection - Unmarked Crosswalk Intersection - Other4 Midblock - Marked Crosswalk 4 Midblock - Marked Crosswalk Travel Lane - Other Location 6 Bicycle Lane 7 shoulder/roadside st nd SEAT ROW OTHER Not Applicable Sleeper Section of Truck Cab Other Enclosed Cargo Area 4 Unenclosed Cargo Area Trailing Unit 6 Riding on Motor Vehicle Exterior (nontrailing unit) ALCOHOL TEST TYPE: Blood Breath Urine 77 Other, Explain in Non-Motorist Actions/Circumstances No Improper Action Dart/Dash Failure to Yield Right-of-Way 4 Failure to Obey Traffic Signs Signals, or Officer In Roadway Improperly (standing, lying, working, playing) 6 Disabled Vehicle Related (working on, pushing, leaving/approaching) ALCOHOL TEST RESULT: PENDING COMPLETED 88 UNKNOWN DRIVER Drivers Actions (HU) DOT-Compliant Motorcycle Helmet Other Helmet No Helmet ALCOHOL/DRUG/EMS BAC EXPIRES 7/8/0 at Time of Crash 6 Ran off Roadway 7 Disregarded other Traffic Sign 8 Disregarded Other Road Markings 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 77 Other Contributing Action 0 INJURY SEVERITY (INJ) None 4 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 4 Deployed-Side 7 Deployed-Curtain 88 Deployment Unknown 8 Sidewalk Median/Crossing Island 0 Driveway Access Shared-Use Path or Trail Non-Trafficway Area 7 Entering/Exiting Parked/Standing Vehicle 8 Inattentive (talking, eating, etc) Not Visible (dark clothing, no lighting, etc.) SUSPECTED DRUG USE: No rd 4th DRIVER OR PASSENGER Action Prior to Crash Crossing Roadway Waiting to Cross Roadway Walking/Cycling Along Roadway with Traffic (in or adjacent to travel lane) 4 Walking/Cycling Along Roadway Against Traffic (in or adjacent to travel lane) Condition At Time of Apparently Normal Asleep or Fatiuged Ill (sick) or Fainted 6 Seizure, Epilespsy, Blackout 7 Physically Impaired 8 Emotional (depression, angry, disturbed, etc.) Under the Influence of Medications/Drugs/Alcohol Restraint Systems (RS) Not Applicable (non-motorist) None Used - Motor Vehicle Occupant Shoulder and Lap Belt Used 4 Shoulder Belt Only Used Lap Belt Only Used 6 Restraint Used - Type Unknown 7 Child Restraint System - Forward Facing 8 Child Restraint System - Rear Facing 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.) 7 Adjacent to Raodway (e.g., shoulder, median) 8 Going to or from School (K-) Working in Trafficway (incident response) 0 None DRUG TEST TYPE: Blood Urine 77 Other, Explain in DRUG TEST RESULT: Positive Negative Pending Not Transported EMS Law Enforcement Not Transported EMS Law Enforcement HSMV 000 S