State of Nebraska Investigator s Motor Vehicle Accident Report Local No./ District MILEPOST

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Meryl Cannon
6 years ago
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1 064 A/ A/ B C D V/ V/ E F V/ V/ G H I V/O V/O V/P V/P J V/Q V/Q K AE Total umber of Vehicles DATE PLACE ROAD O WHICH OCCURRED DISTACE FRO ILEPOST R. WORK ZO CODES COUTY CITY VEHICLE (VI) State of ebraska Investigator s otor Vehicle Accident Report Local / District FEET STREET/ HIGHWAY IF AT ITERSECTIO AE ITERSECTIG ROADWAY Agency Case / D D / Y Y Y Y S E W S. PEDESTRIA CLASSIFICATIO CODES GC DL SUV (/L) SIL S T W TH F S ILEPOST FEET PRIVATE PROPERTY? LOGITUDE O-WAY STREET? HIGHWAY SHOULD LOCATIO HAVE EGIERIG STUDY? IF T AT ITERSECTIO LATITUDE AREST STREET, BRIDGE, RAILROAD CROSSIG EDICAL FACILITY AE ES SERVICE AE ES RU REPORT - Regional West edical Center - orth Unit - S E W HIT & RU? IF WAS OUTSIDE CITY LIITS, IDICATE DISTACE FRO AREST TOW S E W AD S E W AREST CITY OR TOW R R R R4 ASELO A CAACHO 7 AVE H,, SCOTTSBLUFF,, AVE H,, SCOTTSBLUFF,, 696,,,, 00 /6 ASELO A CAACHO PA PD Impou Ronald Allen H C407 GKFK66UJ TIE POLICE TIFIED S S S S4 S5-a S5-b S6-a S6-b Towing VEHICLE VEHICLE (In ilitary Time) ( 08 ) CITATIO PEDIG (Plate Expires) POLICY IVESTIGATIO ADE AT SCE? USE OLY Sheet of DOES IVOLVE DAAGE TO DEPT. ROADS PROPERTY? CITATIO SE CITATIO CITATIO 008 City Route,,,, 696 PEDIG AP 4645 (Plate Expires) 0 VEHICLE 008 Ford F-550 Single Unit Tru WHI (VI) FDAF57R58EC75698 Emasco POLICY Complete this section for all injured persons (Complete a continuation report, if more than three were injured) ( 08 ) SE FE FE 4 5 SE Seat Eject Body Injury Position Region Sev. Trans. F Anselmo A Camacho, 7 Ave H,,, e, West 6th Street ( 08 ) E-5-8 A State Farm 968-C06-7D L V/ 9 V/ V/ V/4 V/5 9 V/6 5 V/ 8 V/ 9 V/ V/4 V/5 V/6 5 AE EDICAL FACILITY AE ES SERVICE AE ES RU REPORT AE EDICAL FACILITY AE ES SERVICE AE ES RU REPORT DR Form 40, Jan 09 THIS FOR REPLACES DR FOR 40, JA 0 PREVIOUS EDITIOS WILL BE DESTROYED.

2 THE FOLLOWIG IFORATIO IS REQUIRED FOR ALL S IDICATE BY DIAGRA WHAT HAPPED AGECY CASE Indicate orth by Arrow DESCRIPTIO BASED O FICER S IVESTIGATIO Vehicle was north bound on from west 6th. Driver # said he fell asleep and ran in to the back of vehicle. This caused vehicle to be pushed into vehicle. Driver # was arrested for driving under the influence. See report # PROPERTY WITSSES VEH S E W OBJECT AE APPRO. COST DAAGE $ OBJECT AE APPRO. COST DAAGE $ AE AE VEHICLE OVEET BEFORE COLLISIO Essentially straight ahead 0 Backing 0 Changing lanes 04 Overtaking/ Passing Turning right ROAD OR HIGHWAY AE 06 Turning left 07 aking U-turn 08 Entering 09 Leaving 0 Parked Slowing or stopped in traffic Other Unknown POIT AD (Enter numbers for each vehicle) VEHICLE POIT 00 one 09 Top & windows 0 Undercarriage Total (all areas) Other VEHICLE POIT FICER TROOP/ DEPARTET TEA/ BEAT -6 IVESTIGATOR AE (Print or Type) IVESTIGATOR SIGATURE ERIQUE RODRIGUEZ 0 0 AIRBAG DEPLOYED VEHICLE 4 Deployed - front Deployed - side Deployed - both front/side 4 ot deployed 5 ot applicable/ o airbag available 6 Unknown VEHICLE 7906 Police Department RESTRAIT USE VEHICLE one used - vehicle occupant Lap & shoulder belt used Shoulder belt only used 4 Lap belt only used 5 Child safety seat used 6 Child booster seat used 7 DOT approved helmet used 8 Costume helmet used 9 Restraint use unknown VEHICLE Digital Certificate with ebraska Crime Commission TOTAL OCCUPATS TESTIG LEVEL TESTED BAC LEVEL / DRUGS SUSPECTED Driver Driver Pedes- trian Y Y Y Driver Driver either alcohol nor drugs suspected Yes - alcohol suspected Yes - drugs suspected 4 Yes - alcohol & drugs suspected 5 Unknown REPORT VEH VEH Photographs taken? 0 07/0/0

3 Vehicle Codes from Overlay # O P Q O P Q Local / District ROAD O WHICH OCCURRED,,,, WILBER J SIR State of ebraska Investigator s otor Vehicle Accident Continuation Report PLACE COUTY CITY STREET/HIGHWAY CITATIO CITATIO 609 COWE DRIVE,, SCOTTSBLUFF,, 696 PEDIG TC 6008 (Plate Expires) 0 VEHICLE 994 Chevrolet S4 Pickup truck BLU (VI) GCDT9Z6R Geico POLICY n/a VEHICLE (VI) /6 n/a Agency Case VEHICLE VEHICLE ( 08 ) CITATIO PEDIG (Plate Expires) POLICY CITATIO Sheet of SE SE USE OLY 000 FE FE Sequence of Events VEHICLE OVEET BEFORE COLLISIO ROAD OR HIGHWAY AE VEH S E W 0 Essentially straight ahead 0 Backing 0 Changing lanes 04 Overtaking/ Passing Turning right AE 06 Turning left 07 aking U-turn 08 Entering 09 Leaving 0 Parked Slowing or stopped in traffic Other Unknown POIT POIT AD (Enter numbers for each vehicle) 0 00 one 09 Top & windows 0 Undercarriage Total (all areas) Other POIT Complete this section for all injured persons AIRBAG DEPLOYED Deployed - front Deployed - side Deployed - both front/side 4 ot deployed 5 ot applicable/ o airbag available 6 Unknown RESTRAIT USE one used - vehicle occupant Lap & shoulder belt used Shoulder belt only used 4 Lap belt only used 5 Child safety seat used 6 Child booster seat used 7 DOT approved helmet used 8 Costume helmet used 9 Restraint use unknown TOTAL OCCUPATS TESTIG LEVEL TESTED BAC LEVEL / DRUGS SUSPECTED Y Y 4 5 SE Seat Eject Body Injury Position Region Sev. Trans. F EDICAL FACILITY AE ES SERVICE AE ES RU REPORT VEH VEH 000 Driver Driver Driver Driver either alcohol nor drugs suspected Yes - alcohol suspected Yes - drugs suspected 4 Yes - alcohol & drugs suspected 5 Unknown AE EDICAL FACILITY AE ES SERVICE AE ES RU REPORT AE EDICAL FACILITY AE ES SERVICE AE ES RU REPORT DR Form 40a, Jan 09 THIS FOR REPLACES DR FOR 40a, JA 0 PREVIOUS EDITIOS WILL BE DESTROYED.

4 ADDITIOAL - DIAGRA & IFORATIO AS REQUIRED FOR AGECY CASE Indicate orth by Arrow PROPERTY WITSSES OBJECT AE APPRO. COST DAAGE $ OBJECT AE APPRO. COST DAAGE $ AE AE FICER TROOP/ DEPARTET TEA/ BEAT IVESTIGATOR AE (Print or Type) ERIQUE RODRIGUEZ -6 IVESTIGATOR SIGATURE 7906 Police Department Digital Certificate with ebraska Crime Commission REPORT 07/0/0 0

5 064 /DISTRICT COUTY CITY AGECY CASE (Print or type full name) CARRIER AE (Print or type full name) Ron's Towing CARRIER (Street or R.F.D.) TRAILER COERCE CLASSIFICATIO Interstate Commerce Intrastate Commerce ot Applicable Did vehicle have a Haz at Placard? Yes o (Print or type full name) State of ebraska Investigator s Supplemental Truck and Bus Accident Report This form must be completed in addition to the DR Form 40, Investigator s otor Vehicle Accident Report, if any of the vehicles involved meet the criteria listed on the back of this form. Year TRUCK WIDTH (Widest part of truck or trailer) inches 0 inches Other (Specify) HAZARDOUS ATERIAL IVOLVED Placard Information: -Digit Hazard Class umber from bottom of Diamond Placard. -Digit OCCURRED O HIGHWAY/ROAD/STREET 008 City Route,,, 696 A B O C Was hazardous cargo released? (Do not count fuel from fuel tank) Yes o TRUCK / BUS - State S CLASS CODE CARRIER IDETIFICATIO TRUCK / BUS - GROSS VEHICLE WEIGHT RATIG (GVWR) or GROSS COBIATIO VEHICLE WEIGHT RATIG (GCVWR) (Combined rating for vehicles and trailers) VEHICLE COFIGURATIO Single-Unit Truck (0,00 6,000 Lbs. GVWR) Single-Unit Truck (Greater than 6,000 Lbs. GVWR) 4 Truck Tractor (bobtail) 5 Truck with Trailer 6 Tractor with Semi-Trailer 7 Tractor with Doubles 8 Tractor with Triples 9 Unknown Heavy Truck 7 Bus (seats 9-5, including driver) 8 Bus (seats 5+, including driver) 9 Haz at Passenger Car 40 Haz at Light Truck (van, mini van, pickup, sport utility) (0,000 Lbs. or less GVWR) Sheet of USE OLY U.S. DOT ICC C ,000 Lbs. or Less (Requires Haz at Placards) 0,00 Lbs. 6,000 Lbs. ore than 6,000 Lbs. CARGO BODY TYPE Bus (seats 9-5, including driver) Bus (seats 5+, including driver) Van/Enclosed Box 4 Grain/Chips/Gravel 5 Pole 6 Cargo Tank 7 Flatbed 8 Dump 9 Concrete ixer 0 Auto Transporter Garbage/ Refuse Other (Specify) Unknown BUS USE ot a Bus Charter Bus 5 Intercity Bus 7 Other Transit Bus 4 School Bus 6 ot Reported CARRIER IDETIFICATIO U.S. DOT ICC C CARRIER AE (Print or type full name) CARRIER (Street or R.F.D.) TRAILER 96 inches Interstate Commerce 0 inches Intrastate Commerce Other (Specify) ot Applicable HAZARDOUS ATERIAL IVOLVED Did vehicle have a Haz at Placard? Yes o COERCE CLASSIFICATIO Year Placard Information: -Digit Hazard Class umber from bottom of Diamond Placard. -Digit TRUCK WIDTH (Widest part of truck or trailer) State S CLASS CODE A B O C Was hazardous cargo released? (Do not count fuel from fuel tank) Yes o GROSS VEHICLE WEIGHT RATIG (GVWR) or GROSS COBIATIO VEHICLE WEIGHT RATIG (GCVWR) (Combined rating for vehicles and trailers) VEHICLE COFIGURATIO Single-Unit Truck (0,00 6,000 Lbs. GVWR) Single-Unit Truck (Greater than 6,000 Lbs. GVWR) 4 Truck Tractor (bobtail) 5 Truck with Trailer 6 Tractor with Semi-Trailer 7 Tractor with Doubles 8 Tractor with Triples 9 Unknown Heavy Truck 7 Bus (seats 9-5, including driver) 8 Bus (seats 5+, including driver) 9 Haz at Passenger Car 40 Haz at Light Truck (van, mini van, pickup, sport utility) (0,000 Lbs. or less GVWR) 0,000 Lbs. or Less (Requires Haz at Placards) 0,00 Lbs. 6,000 Lbs. ore than 6,000 Lbs. CARGO BODY TYPE Bus (seats 9-5, including driver) Bus (seats 5+, including driver) Van/Enclosed Box 4 Grain/Chips/Gravel 5 Pole 6 Cargo Tank 7 Flatbed 8 Dump 9 Concrete ixer 0 Auto Transporter Garbage/ Refuse Other (Specify) Unknown BUS USE ot a Bus Charter Bus 5 Intercity Bus 7 Other Transit Bus 4 School Bus 6 ot Reported IVESTIGATOR AE (Print or type) IVESTIGATOR SIGATURE DEPARTET FICER REPORT ERIQUE RODRIGUEZ DR Form 74, Jan 09 THIS FOR REPLACES DR FOR 74, JA 0 AIL TO: Accident Records Bureau, ebraska Department of Roads, PO Box 94669, Lincoln, PREVIOUS EDITIOS WILL BE DESTROYED. Digital Certificate with ebraska Crime Commission 7906 Police Departmen 07/0/0

State of Nebraska Investigator s Motor Vehicle Accident Report Local No./ District MILEPOST

State of Nebraska Investigator s Motor Vehicle Accident Report Local No./ District MILEPOST 05373 A/ A/ B C D V/M V/M E F V/ V/ G H I V/O V/O V/P V/P J V/Q V/Q K 00 0 39 06 05 5 0 4 0 AME Total umber of Vehicles DATE ACCIDET PLACE ACCIDET ROAD O WHICH ACCIDET OCCURRED DISTACE FROM MILEPOST R.