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TRAFFIC CRASH REPORT *DENOTES MANDATORY FIELD FOR SUPPLEMENT REPORT

OH-2PHOTOSTAKEN

‘OH-1P OTHER

SECONDARY CRASHPRIVATE PROPERTY

LOCAL tNFORMATION

LOCAL REPORT NUMBER*

/9 382REPORTING AGENCY NAMER NCIC* HIT/SKIP I NUMBER Or UNITS I UNIT IN ERROR

1-SOLVED I 98- ANIMALO 72 L_J 2- UNSOLVED1 10 3 L?L3J 99- UNKNOWN

ROADWAY

1-CITY ICOUNTY* LOCALITY* I LOCATION: CITY, VILLAGE,TOWNSHIP* CRASH DATE/TIME* CRASH SEVERITY

b 7 / 2vILLAGE I[L/l2IC/I JlV7

EZ 1-FATAL

2-SERIOUS INJURYL_i_J_3-TOWNS[IIPI

ROUTETYPE ROUTE NUMBER PREFIX 1 NORTH LOCATION ROAD NAME ROAD TYPE LATITUDE DECIMAL DEGREES SUSPECTED

,_

2-SOUTH3-MINOR INJURY3- EAST j ,1i1 / 7 I 7 SUSPECTEDI II I I I IL___J4WEST

ROUTETYPE ROUTE NUMBER PREFIX 1- NORTH REFERENCE ROAD NAME (ROAD, MILEPOST, HOUSE #) ROADTYPE LONGITUDE DECIMAL DEGREES 4- INJURY POSSIBLE2 - SOUTH

5- PROPERTY DAMAGE3- EAST / 7 72 I I ONLYI I II I I I I IL_J4-WEST

REFERENCE POINT DIRECTION ROUTE TYPE ROAD TYPE INTERSECTION RELATED1 - INTERSECTION

FRCM REFERENCE1- NORTH IR - INTERSTATE ROUTE(TP) AL - ALLEY OW- HIGHWAY RD - ROAD WITHIN INTERSECTION OR ON APPROACH3R

2- MILE POST 2- SOUTH us - FEDERAL US ROUTE AV - AVENUE LA - LANE SQ - SQUAREIIL___J 3- HOUSE # L-—_J 3- EAST

BL - BOULEVARD MP - MILEPOST ST - STREET E WITHIN INTERCHANGE AREA NUMBER OF APPROACHES4-WEST SR-STATE ROUTECR -CIRCLE OV -OVAL TE -TERRACE

DISTANCE DISTANCE CR - NUMBERED COUNTY ROUTEFROM REFERENCE UNIT OF MEASURE CT - COURT PK - PARKWAY TL -TRAIL

1-MILES TR-NUMBEREDTOWNSHIP DR-DRIVE PT -PIKE WA-WAY2-FEET ROUTE

, i:i ROADWAYDIVIOED -

I j] 3 -YARDS -HE - HEIGHTS PL - PLACE

LOCATION or FIRST HARMFUL EVENT MANNER Or CRASH COLLISION/IMPACT DIRECTION or TRAVEL MEDIAN TYPE1- ON ROADWAY 9- CROSSOVER 1- NOT COLLISION 4- REAR-TO-REAR 1- NORTH 1- DIVIDED FLUSH MEDIAN

I O L2-ON SHOULDER 1O-DRIVEWAY/ALLEVACCESS BETWEEN BACKING 2 SOUTH 1<4 FEET)

TWO MOTOR -

—— 3-IN MEDIAN H- RAILWAY GRADE CROSSING VEHICLES IN 6- ANGLE 3- EAST 2- DIVIDED FLUSH MEDIAN

4- ON ROADSIDE 12-SHARED USE PATHS OR TRANSPORT 7-SIDESWIPE, SAME DIRECTION ( 4 FEET)4 -WEST

5- ON GORE TRAILS 2- REAR-END 8-SIDESWIPE, OPPOSITE DIRECTION 3-DIVIDED, DEPRESSED MEDIAN

6- OUTSIDE TRAFFIC WAY 13-BIKE LANE 3- HEAD-ON 9-OTHER! UNKNOWN 4-DIVIDED, RAISED MEDIAN

7-ON RAMP 14-TOLL BOOTH (ANYTYPE)

8- OFF RAMP 99-OTHER / UNKNOWN 9- OTHER/UNKNOWN

fl WORK ZONE RELATED WORK ZONE TYPE LOCATION OF CRASH IN WORK ZONE CONTOUR CONDITIONS SURFACE

1-LANE CLOSURE 1-BEFORETHE 1ST WORK ZONE

J WORKERS PRESENT 2-LANE SHIFT/CROSSOVER WARNING SIGN L_LJLAWENFDRCEMENTPRESENT

3-WORKONSHOULDER 2-ADVANCEWARNINGAREA 1-STRAIGHTLEVEL 1-DRY 1-CONCRETE

OR MEDIAN I____I 3 -TRANSITION AREA 2-STRAIGHTGRADE 2-WET 2-BLACKTOF4- INTERMITTENT OR MOV1NG WORK 4- ACTIVITY AREA BITUMINOUS,

ACTIVE SCHOOL ZONE 5-OTHER 5-TERMINATIONAREA3-CURVE LEVEL 3-SNOW ASPHALT

4-CURVEGRADE 4-ICE 3- BRICK/BLOCKLIGHT CONDITION WEATHER 9- OTHER/UNKNOWN 5- SAND, MUD, DIRT, 4- SLAG, GRAVEL,

1-DAYLIGHT 1-CLEAR 6-SNOW OIL,GRAVEL STONE

J 2-DAWN/DUSK 2-CLOUDY 7-SEVERECROSSWINDS 6-WATERISTANDING, 5-DIRTCLJ 3- DARI< — LIGHTED ROADWAY 3- FOG, SMOG, SMOKE 8- BLOWING SAND, SOIL, DIRT, SNOW - MOVING)9- OTHER/UNKNOWN

4- DARK — ROADWAY NOT LIGHTED 4- RAIN 9- FREEZING RAIN OR FREEZING DRIZZLE 7- SLUSH

5- DARK — UNKNOWN ROADWAY LIGHTING 5- SLEET, HAIL 99-OTHER! UNKNOWN 9- OTHER/UNKNOWN9-OTHER/UNKNOWN

-r -r -r - r —> Indicate the northNARRATIVEV 112 -3 tcir’ ve%’ - - 44 / J A —

—

direction withan”N”on the

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compass diagram.

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-.---- -,-----

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I- .5-

ZZZiiZCRASH REPORTED DATE/TIME DISPATCH DATE/TIME ARRIVAL DATE/TIME I SCENE CLEARED DATE/TIME REPORTTAKENBY

01 /I Z4/ 171 I/I t1 JI2IOlJ (9 /2% ?POLICE AGENCY

TOTAL TIME OTHER TOTAL I OFFICER’S NAME* I CHECKED OY OFFR’S NAME* EJ MOTORIST

ROADWAY CLOSED IINVESTIGATION TIME MINUTES j ,,L Ii SUPPLEMENT

L___I (CORRECTIONs, ADDITIONOFFICER’S BADGE NUMBER* I CHECKED BY OFFICER’S BADGE NUMBER* IOANERISTINGR,R,RE,E,E,,,ER,I

I II 0 I I ?IjL_%t I I LL I I I I L_1

HSY7001 OHI 1/19 [760-0820] PAGE / OF /I (,

UNIT

UNIT # OWNER NAME: LAST, FIRST, MIDDLE )AMEAS DRIVER)

• I

OWNER AOORESS: STREET, CITY STATE, ZIP )VVREAD DRIVER)

— COMMERCIAL CARRIER: NAME,ADDRESS, CITY, STATE, ZIP

25 -IOIPACTAUENUATOR)CRASH CUSHION

26-BRIDGEOVERHEAESTRUCTURE

5) , I M-HEDIANGUARDRAIL27-BRIDGE PIER SR ABUTMENT BARRIER20-BRIDGE PURUPET 35-MEDIAN CONCRETE

_________

29-BRIDGE RAIL BARRIER

30-GUARDRAIL FACE 30-MEDIAN OTHER BARRIER

I I FERST HARMFUL EVENT _LJ MOST NARMEUL EVENT

OWNER PH ONE: )VDLVDE AREA DDDE ),DAVE AS DRIVER)

I I I I I I I I I I

SO-WORK ZONE MAINTENANCEEQUIPMENT

5D -WALLS2-IUILDING53-TUNNEL

54-OTHER FIXED OBJECT99-OTHER)UNKNDWN

UNIT! NON-MOTORIST OIRECTION

- NORTH S-NORTHEAST

2- SOOTH 6-NORTHWEST

FROM LJ TO )_ 3 - EAST 7 - SOUTHEAST

4-WEST 8-SOUTHWEST

- OTHER) UNKNOWN

/ D - STATED I ESTIMATED SPEED

2 -CALCULATEDIEDR

3-UNDETERMINED

LOCAL REPORT NUMBER

,“198I3I81Z1 I I I

LP STAT LICENSE PLATE # VEHICLE IDENTIFICATION # VEHICLEYEAR VEHICLE MAKE

___

//J(2c2 /1t qv7i,ri ‘CL I/I 919171 (#61/fr’

COMMERCIAL CARR:ER PHONE: INCLVDEAEEA CDDE

I I I I I I I I I

DAMAGE SCALE

- NONE 3-FUNCTIONAL DAMAGE

_______I

2- MINOR DAMAGE 4- DISABLING DAMAGE

9-UNKNOWN

OAMAGEO AREA(S)INDICATE ALLTHAT APPLY

INSIOANCE I INSURANCE COMPANY I INSURANCE POLICY # I COLOR I VEHICLE MOOELVERIFIEO PIMP xar 34L16 A

TYPE OF USE US DOT K I TOWED BY: COMPANY NAMEIN EMERGENCY IC COMMERCIAL flGOVERNMENT C RESPONSE ) I I I I

HAZAROOUS MATERIALINTERLOEK I #OCCUPANTS

VEHICLE WEIGHT GVWRIGEWRMATERIAL CLASS # PLACARI 10 it

EQUIPPEO ‘01 /1 I/I 3 ->26KLRD PLACARD IIC DEVICE HIT!SKIP UNIT I 1 - sOOK LED RELEASED

2 - 10,001 - 26K LEO

0 - PASSENGER CAR 7- MOTORCYCLE 2-WHEELED 02 -GOLF CART 18 -LIMO ILIVERY VEHICLE) 23-PEDESTRIAN) SKATER2- PASSENGER VAN )MINIVAN) B - MOTORCYCLE 3-WHEELED 03 -SNOWMOBILE SQ -BUS)D6. PASSENGERS) 24 -WHEELCHAIR )ANYTYPE)-O—- 3- SPORT UTILITY VEHICLE 9- AUTOCYCLE 34 -SINGLE UNITTRACK 20-OTHER VEHICLE 25 -OTHER NON-MOTORIST

UNIT TYPE 4-PICKUP DO - FOPED OR MOTORIZED 15 -SEMI-TRACTOR 21- HEAVY EQUIPMENT 20 -BICYCLE

5- CARGOVAN BICYCLE DO-FARM EQUIPMENT 22-ANIMAL WITH RIDERAR 27-TRAIN

U - YAN )9-D5 SEATS) SD -ALLTERRAIN VEHICLE D7 -MOTORHOHE ANIMAL-DRAWN VEHICLE 99- UNKNOWN OR HWSKIP)ATY)

LQ_J # OFTRAILSNG

WAS VEHICLE OPERATING IN AUTONOMOUS 0 - NQAUTO9ATIOS 3 -CONDITIONALAUTDMATION 9- UNKNOWNMODE WHEN CRASH OCCURRED? p 1 - DRIVERASSISTANCE 4 - HIGH AUTOMAYION

1-YES 2-NO 9-OTHER)UNKNOWN AUTONOMOUS 2- PARTIALAUVOHATION 5- FULLAUTOMATIONMODE LEVEL

1 - NONE 6- BUS— CHARTEBTOXR Dl - FIRE DO-FARM 21 -MAIL CARRIER

I_O_L) 2- TAXI 7- BUS— INTERCITY 12- MILITARY 17- MOWING 99 -OTHER) UNKNOWN

3- ELECTRONIC RIDE SHARING B - BUS—SHUffLE 13 -POLICE DO-SNOW REMOVALSPECIALFUNCTION 4 -SCHOOLTRANSPOOT 9- BUS—OTHER 14-PUBLIC UTILITY 19-TOWING

5- BUS —TRVNSff)CDRHUTER 10 -AMBULANCE 15 -CONSTRUCTION EQUIPMENT 20 -SAFETY SERVICE PATROL

1 - NO CARGO DDDVTYPE 3- VEHICLETOWING VNOTHER 5 - INTERMODAL CONTAINER B - POLE 32 -CONCRETE MIXERQJj )NUT APPLICABLE MOTOR VEHICLE CHASSIS 9- CARGOTANK D3-AUTOTRANSPORTERCARGO 2- BUS 4- LOGGING 6- CARGO VVN)ENCLDSED BOX lU-FLAT BED 14-GARDAGOHEFUSEBODYTYPE 7 - GRAIN)CHIPS)GRAVEL Dl -DUMP 99-OTHER) UNKNOWN

B - TURN SIGNALS 4- BRAKES 7 - WORN DR SLICKTIRES 9- MDTDRTRDUBLE 99-OTHER) UNKNOWN‘I,

VEHICLE 2- HEAD LAMPS S - STEERING B- TRAILER EQUIPMENT 3D-DISABLED FROM PRIORDEFECTS 3- TAIL LAMPS U - TIRE BLOWOUT DEFECTIVE ACCIDENT

1 - INTERSECTION — MARKED 3 - INTERSECTION — OTHER 6- BICYCLE LANE 9- MEDIAN)CROSSING ISLAND 12- FIRST RESPONDERL_J_J CROSSWALK 4 - MIDBLDCK — MARKED 7 - SHOULDER) ROADSIDE 10- DRIVEWAY ACCESS AT INCIDENT SCENE

DIN-MOTORIST 2- INTERSECTION — UNMARKED CROSSWALK B - SIDEWALK Dl -SHARED USE PATHS DR 99 -OTHER) UNKNOWNLOCATION CROSSWALK 5 -TRAVEL LANE—ODoR LD:AV:S TRAILSAT

D2 D2 AD

R9A R 3 R 3 R

Q-N0DAMAGE[o] Q-UNDERCARRIAGE C14]

1- NON—CONTACT 1 - STRAIGHTAHEAD 7- MAKING U-TURN 13 -NEGOTIATING A CURVE DO-APPROACHING

2- NON—COLLISION 2- lACKING B- ENTEOINGTRAFFIC LANE 14 -ENTERING OR CROSSING OR LEAVING VEHICLE

3- STRIKING LL±/J 3 - CHANGING LANES 9 - LEAVINGTRAFFIC LANE SPECIFIED LOCATION 19 -STANDING

4- STRUCK PRE-ERASH 4 - OVERTAKING)PASSING DO -PARKED 15 -WALKING, RUNNING, 20 -OTHER NON-MOTORISTACTIONS JOGGING, PLAVING 21-STANDING OUTSIDE5- BOTH STRIKING S - MAKING RIGHTTURN Dl -SLOWING OR STOPPED

&STRUCK 6- MAKING LEFTTXRN INTOAFPIC 16-WORKING DISABLED VEHICLE

9 - OTHER) UNKNOWN 12 -DRIVERLESS 17-PUSHING VEHICLE 99-OTHER) UNKNOWN

Q-T0P [131 Q-ALLAREAS [151

Q-UNIT NOTAT SCENE [161

INITIAL POINT OF CONTACT

0-NO DAMAGE 14- UNDERCARRIAGE

ó7 1-12-REFERTO UNIT 15-VEHICLE NOTAT SCENEI I DIAGRAM 99 UNKNOWN

13-TOP

1- NONE 7 -LEFT OF CENTER 13 -IMPROPER START FROM A 17 -VISION OBSTRUCTION 21- LYING IN ROADWAY2- FVILURETOYIELD B -FOLLOWINGTDD CLOSE )ACDA PARKED POSITION 10 -OPERATING DEFECTIVE 22- NOT DISCERNIBLE

14 -STOPPED OR PARKED EQUIPMENT 23-OPENING DOOR INTOL?/ 3-OHNREDLIGHT 9-IMPROPERLANECHHNGEILLEGALLY

4- RAN STOP SIGN DO-IMPROPER PASSING 19 -LOAD SHIFTING)FULLING) ROADWAYCONTRIIITING 15 -SWERVINGTOAVOID SPILLING 99-OTHER IMPROPERACTIONS-UNSAFE SPEED DD-DROVE OFF ROADEIRCUMITHNCIB 16-WRONG WAY 20-IMPROPER CROSSING

6-IHPRDPERTURN 12-IMPROPER BACKING

SEQUENCE OF EVENTS

TRAFFOC

DI 2 I 012 - FIRDEXPLOSION

3-IMMERSION2) I I 4-JACKKNIFE

5- CARGD)EQUIPMENTLOSSDRSHIFT

3) I

TRAFFIC WAY FLOW

- ONE-WAY

.2 2 - TWO-WAY

6- EQUIPMENT FAILURE

7-SEPARATION OF XNITS

- RAN OFF ROAD RIGHT

9- WN OFF ROAD LEFT

DO-CODSS MEDIAN

TRAFFIC CONTROL

1-ROUNDABOUT 4-STOP SIGN

2 - SIGNAL 5 - YIELD SIGN

3-FLASHER 6-NOCONTROL

NON-COLLISION11 -CROSS CENTERLINE — 16- RAILWAY VEHICLE 22 -WORK ZQNE MAINTENANCE

OPPOSITE DIRECTION OF 17 -ANIMAL — FARM EQUIPMENTTRAVEL 10-ANIMAL — DEER 23 -STRUCK OY FALLING,

12- DOWNHILL RUNAWAY SHIFTING CARGO OR19 -ANIMAL — OTHER13-OTHER NON-COLLISION ANYTHING SET IN MOTION

2O-MDTDRXEHICLE IN BYA ROTOR VEHICLE14-PEDESTRIAN TRANSPORT 24-OTHER MOVABLE OBJECT15-PEDHLCYCLE 21-PARKED MDTOD VEHICLE

it OF THROUGH LANESON ROAD

LL

RAIL GRADE CROSSING

- NOT INVOLVED

2- INHOLXEO-ACTIVE CROSSING

3-INVOLVED-PASSIVE CROSSING

COLLISION WITH FIXED OBJECT — STRUCK31-GUARDRAIL END 37-TRAFFIC SIGN POST 43-CURD32-PORTABLE BARRIER 38-OVERHEAD SIGN POST 44-DITCH33- 9EDIAN CABLE BARRIER 39- LIGHT) LUMINARIES 4S-EMBANKMENT

SUPPORT 40-FENCE40-UTILITY POLE 47-MAILBOX41-OTHER PIST POLE 40-TREE

OR SUPPORT49-FIRE HYDRHNY

42-CULVERT

UNIT SPEED

UI I

DETECTED SPEED

POSTED SPEED

13151

PAGE % OF5HSYH3O4 OHTU 1130 [7H0-OH2D]

OHIO OEPAWDMEFff I IU NIT

UNIT # OWNER NAME: LAST, FIRST, MIDDLE IVVOEVD DRIVER)

OWNER AODRESS: STREET; CITY STATE, ZIP )SRVEVV DRIVER)

COMMERCSAL CARRIER: SAME,ASDRESS, CITY, STATE, ZIP

OWNER

I I I I I I I

LOCAL REPORT NUMBER

I I I

INSURANCE ENSURANCE COMPANY

iJ VERIFIEB

LP STATE L CENS PLATE # VEHICLE IOENTIFICATION # VEHICLE YEAR VEHICLE MAKE

zi ázlstve (1 2kS5) 2Ooaj(//,ay

CaMMEHC:AL CRRRIRR PHONE: TNCLVDE RREV CODE

INSURANCE POLICY #

Q o3&oo3qBo

OAMAGE SCALE

1-NONE 3-FUNCTIONAL OAMAGE

_______

2-MINOR OAMAGE 4- OISABLING OAMAGE

9- UNKNOWN

US DOT A

COLOR VEHICLE Mi

/TOWED BY: COMPANY NAME

DAMAGEO AREA(S)INOICATE ALL THAT APPLY

TYPE OF USE

Q COMMERCIAL Q GOVERNMENT fl IN EMERGENCY IRESPONSE I

HAZAROOUS MATERIALINTERLOCK I #OCCUPANTS

VEHICLE WUCHTGVWR/GEWRMATERIAL CLASS # PLACARO 10 #

I 3- >26KLRS. C PLACARD II I I )

cI OEVICE HIT/SKIP UNIT -

— LOS. RELEASEDEQUIPPEO

I Q f_ 7 2- 1O,001-26KLRS

1 - PASSENGER CAR 7- MOTORCYCLE 2-WHEELED 12 -GOLF CART 10-LIMO )LIAERYYEHICLE) 23- PEDESTRIAN (SKATER

2 - PASSENGER VAN (MINT/AN) 0 - MOTORCYCLE 3-WHEELEO 13 -SNOWMOBILE 19-lOS (16+ PASSENGERS) 24-WHEELCHAIR (ANYTYPE)LOi4i 3- SPORT OTILITYVEHICLE 9- AUTOCYCLE 14-SINGLE UNITTRUCK 20-OTHERVEHICLE 25-OTHER NON-MOTORIST

UNITTYPE 4 - PICK OP 10- HOPEO OR MOTORIZED 15-SEMI-TRACTOR 21 -HEAVY EQUIPMENT 26 -BICYCLE

5 -CARGOYAN BICYCLE 16-FARM EQUIPMENT 22-ANIMALWITH RIDERSR 2T-TRAIN

6- VAN (9-15 SEATS) 11 -ALLTERRAIN VEHICLE U7-M000RHRME ANIMAL-DRAWN VEHICLE 99 -UNKNOWN OR HIT)SKIP

Li2Z # oTRAILING UNITS)ATY)UTV)

WASYEHICLE OPERATING IN AUTONOMOUS 0- NOAUTTMATION 3- CONDITIONALAUTRMATION 9- UNKNOWNMOBE WHEN CRASH OCCURREIT 1- DRIVERASSISTUNCE 4- HIGH AUTOMATION

L_J 1-YES 2-NO R-OTHER)UNKNOWN AUTONOMOUS 2- PARTIAL AUTOMATION S - FULLAUTOYATIONMOBE LEVEL

1 - NONE 6- RUS— CHURTEETOUR 11- FIRE 16 -FARM 21-MAIL CARRIER

/ 2- TAUI 7 - BUS - INTERCITY 12- MILITARY 17 -MOWING 99 -OTHER) UNKNOWN

3- ELECTRONIC RIDE SHARING B - BUS - SHUffLE 13 -POLICE UO -SNOW REMOVALSPECIALFUNCTEON - SCHOOLTRANSPIRT 9- BUS—OTHER 14-PUBLIC UTILITY 19-TOWING

5- BUS —TRANSU)COMMUTER 10 -AMBULANCE 15 -CONSTRUCTION EQUIPMENT 20 -SAFETY SERVICE PATROL

1-NO CARGO BODY TYPE 3- VEHICLETOWING ANRTHER S - INTERMODAL CONTAINER B - PILE 12 -CONCRETE MIVERLJ1J )NOTAPPLICABLE MOTORVEHICLE CHASSIS 9- CARGOTANK 13-AUT000ANSPURTERCARGO 2- BUS 4 -LOGGING A -CARGO VAN)ENCLOGED BOO000Y 1O-FLATBEB 14-GARBAGE!REFUSE

TYPE 7- GRAIN)CHIPS)GRAAEL 11 -BUMP 99-OTHER) UNKNOWN

B - TURN SIGNALS 4- BRAKES 7 - WORN OR SLICKTIRES 9- MOTORTROUBLE 99-OTHER) UNKNOWNI_

VEHICLE 2- HEAD LAMPS S - STEERING B - TRAILER EQUIPMENT DO -DISABLED FROM PRIORDEFECTS 3- TAIL LAMPS A - TIRE BLOWOUT DEFECTIVE ACCIDENT

1- INTERSECTION — MARKED 3- INTERSECTION —OTHER 6- BICYCLE LANE 9 - MEDIA N)CROSSING ISLAND 12-FIRST RESPONDERjj CROSSWALK 4 - MIDBLOCK — MARKED 7 - SHOULEER) ROADSIDE 10 - DRIVEWAY ACCESS AT INCIDENT SCENE

MIN-HITIRIST 2- INTERSECTION — UNMARKED CROSSWALK 0 - SIDEWALK 11 -SHARED USE PATHS OR 99 -OTHER) UNKNOWNLOCATION CROSSWALK S -TRAVEL LANE—OTHER LARSON TRAILSAT IMPACT

12 12 12

S93 N 3 9 S S 3

Q-N00AMAGEE0] Q-UNDERCARREAOE [143

1 - NON—CONTACT 1 - STRAIGHTAHEAO 7 - MAKING U-TURN 13 -NEGOTIATING A CURVE DO -APPROACHING

S 2- NON—COLLISION 2- BACKING B - ENTERINGTRAFFIC LANE 14 -ENTERING OR CROSSING OR LEAVING VEHICLE

LJ 3- STRIKING LJLLJ 3 - CHANGING LANES 9 - LEAVING TRAFFIC LANE SPECIFIED LOCATION 19- STANDING

ACTOO N 4- STRUCK PRE-ERASH 4- OVERTAKING)PASSING 10- PARKED 15 -WALKING, RUNNING, 20-OTHER NON-MOTORISTACTIONS JOGGING, PLAYING 21-STANDING OUTSIDES - BOTH STRIKING S - MAKING RIGHTTURN 11 -SLOWING OR STOPPED

A STRUCK 6- MAKING LEFTTURN INTRAFFIC ON-WORKING DISABLED VEHICLE

9-OTHER)UNKNOWN 12-DRIVERLESS 17-PUSHINGVEHICLE 99-OTHER)UNKNOWN

Q-T0P [133 Q-ALL AREAS [153

D-UNITN0TATSCENE [163

INITIAL POINT OF CONTACT

0- NO DAMAGE 14- UNDERCARRIAGE

0 1-12 - REFERTO UNIT 15-VEHICLE NOT AT SCENEOIAGRAM 99- UNKNOWN

13-TOP

1- NONE 7- LEFT OF CENTER 13-IMPROPER START FROM A 17 -VISION OBSTRUCTION 21 -LYING IN ROADWAY

2-FAILURETOYIELO B-FOLLOWINGTOOCLOSE)ACEA PARKED POSITION lI-OPERATING DEFECTIVE 22-NOTDISCERNIULE14-STOPPED OR PARKED EQUIPMENT 23-OPENING BOOR INTO3- RAN RED LIGHT 9- IMPROPER LANE CHANGE

ILLEGALLY4- RAN STOP SIGN 10-IMPROPER PASSING 19 -LOAD SHIFTING)FALLING) ROADWAY

EINTRIIUTIND 15 -SWERVINGTOAVOIO SPILLING 99 -OTHER IMPROPERACTION5- UNSAFE SPEED 11-DROVE OFF ROADCIRCUMSRONEES 16 -WRONG WAY 20-IMPROPER CROSSING6- IMPROFERTURN 12-IMPROPER BACKING

SEGUENCERF EVENTS

TRAFFIC

TRAFFIC WAY FLOW

1- ONE-WAY

2-TWO-WAY

TRAFFIC CONTROL

1- ROUNDABOUT 4-STOP SIGN

2 - SIGNAL S - YIELD SIGN

3-FLASHER A-NOCONTROL

#OF THROUGH LANESON ROAD

RAIL GRADE CROSSING

1 - NOT INVOLVED

2-INVOLVED-ACTIVE CROSSINGLJ

3-INVOLVED-PASSIVE CROSSINGNON-COLLISION

2 611 -OVERTURN!ROLLOVER A - EQUIPMENTFAILURE 11-CROSSCENTERLINE — DA-RAILWAYAEHICLE 22-WORKZONE MAINTENANCE

2- FIRE)EAFLOSION 7- SEPARATION OF UNITS OPPOSITE DIRECTION OF 17 -ANIMAL — FARM EQUIPMENTTRAVEL

2

3- IMMERSION B - RAN OFF ROAD RIGHT 10-ANIMAL — DEER 23-STRUCK BY FALLING,12- DOWNHILL RUNAWAY SHIFTING CARGO OR

_________ 4- JACKKNIFE 9- RAN OFF ROAD LEFT 19 -ANIMAL — OTHER13- OTHER NON-COLLISION ANYTHING SET IN MOTION

20- MOTOR VEHICLE IN BY A MOTOR VEHICLES - CARGO! EQUIPMENT DO-CROSS MEDIAN 14- PEDESTRIAN TRANSPORTLOSS OR SHIFT 24- OTHER MOVABLE OBJECT31 I 15-PEDOLCYCLE 21-PARKEDMOTORVEHICLE

COLLISION WITH FIXED OBJECT — STRUCK23-IMPACTATTENUATOR 31-GUARIRAILEND 37-TRAFFIC SIGN POST 43-CURB SO-WORKZONE MAINTENANCE

4) I )CRASH CUSHION 32 -PORTABLE BARRIER 30 -OVERHEAD SIGN POST 44 -DITCH EQUIPMENT26-BRIDGE OVERHEAD 33 -MEDIAN CABLE BARRIER 39 -UGHT) LUMINARIES 45 -EMBANKMENT SD -WALL

STRUCTURE5 I 34-MEDIAN GUARDRAIL SUPPORT 46-FENCE 52 -BUILDING

27 -BRIDGE PIER OR ABUTMENT BARRIER 40-UTILITY POLE 47- MAIL100 53 -TUNNEL20-BRIDGE PARAPET 35-MEDIAN CONCRETE 41 -OTHER POST POLE 48-TREE S4 -OTHER FIOED OBJECT

6) I I 29 -BRIDGE RAIL BARRIER OR SUPPORT49 -FIRE HYORANT 99-OTHER) UNKNOWN

30-GUARDRAIL FACE 36 -MEDIAN OTHER BARRIER 42 -CULVERT

/ ‘ FIRST HARMFUL EVENT L2iJ MOST HARMFUL EVENT

UNIT / NON-MOTORIST OERECTION

- NORTH S - NORTHEAST

2 - SOUTH A - NORTHWEST

FROM LLJ TO 3-EAST 7-SOUTHEAST

4-WEST 0-SOUTHWEST

9 -OTHER)UNKNOWN

UNIT SPEED DETECTED SPEED

) D -STATED!ESTIMATED SPEED

2-CALCULATEB!EDR

3 - UNDETERMINEOPOSTED SPEED

13)5)

HSYR3D4 OH1U 1/19 [760-08201 PAGE 3 OF&

——4’ OHIO ORPARrOONT

5#1996i5 5ET3Z NIT

23 -IMPACTAIIENUATUR4) I I ICRASHCUSHIRN

26-IRIDGERRERHEADSTRUCTURE

SI I27-BRIDGE PIERORARATMENT

2R-IRIIGE PARAPET

________

29-BRIDGE RAIL3D -GUARDRAIL FACE

COMMERCIAL CARRIER PHONE: IACLUDEAREA CODE

I I I I I I I I I I

COLLDSIONwITH FIXED OBJECT — STRUCK3D -GUARDRAIL END 37-TRAFFIC SIGN PAST 43-CARD

32 -PDRTADLE BARRIER 3R-RRERHEAD SIGN PDST 44-DITCH33-MEDIAN CABLE BARRIER 39-UGHT/ LRMINARIES 45- EMBANKMENT34-MEDIAN GUARDRAIL SDPPRRT 44-FENCE

BARRIER 41- UTILITY PRLE 47- MAILIDA35-MEDIAN CDNCRETE 4D-ATHER PDSTPRLE 4R-TREE

BARRIER RRSAPPDRT49-FIREHYDRANT

34-MEDIAN RTHER BARRIER 42-CALYERT

Q-N0DAMAGEC0I Q-UNOERCARRIAGE £141

Q-T0P E13] Q-ALLAREAS £151

Q-UNITNOTATSCENE £163

UNITIAL POINT AF CONTACT

0- NO DAMAGE 14- UNDERCARRIAGE

/ 1-12-REFERTO UNIT 15-VEHICLE NOTATSCENEDIAGRAM 99- UNI<NDWN

UNIT! NON-MOTORIST DIRECTION

1 - NORTH 5 - NARTHEAST

2- SRATH 6- NRRTHWEGT

FROM LJ TO LJ 3 - EAST 7 - SOUTHEAST

4-WEST I-SRATHWEST

9 -ATHER/ANKNOWN

3’

J 1-STATED I ESTIMATED SPEED

2 -CALCALATED/EDR

3-UNDETERMINED

COMMERCIAL CARRIER: NAME,ADSREUS, CITY, STATE, ZIP

UNIT # OWNER NAME: LAST, FIRST, MIDDLE IDSAREAS DOWER) OWNER PHONE: IRCESOENREAtSSE IQSARESI DOWER)

0)3 YAfls io’zz mnn %gjgsssi, so,OWNER ADDRESS: STREET, CITY STATE, ZIP C500EASDRIVERI

99o0 IYARTEELFofl yj) 2EEEr/:L61/ 4-’VW/ 87Sf

LOCAL REPORT NUMBER

[/9181318121 I I I

LP STAT LICENSE PLATE # VEHICLE IOENTIFICATION # VEHICLE YEAR VEHICLE MAKE

01? #N1/&22B 31GSCL133FO8S61O1W1v1 2 OI&f)l flofl/

DAMAGE SCALE

1-NONE 3-FUNCTIONALDAMAGE

2-MINOR DAMAGE 4-DISABLING DAMAGE

9-UNKNOWN

OAMAGEO AREA(S)INDICATE ALL THAT APPLY

INSIRUNCE I INSURANCE COMPANY I INSURANCE POLICY # COLOR I VEHICLE MODELVERIFIEB Ca/ca 4’vi7SYfldS i&izb

TYPE SF USE US 001 4 TOWEO BY: CAMPANY NAME

D IN EMERGENCY ID COMMERCIAL GOVERNMENT RESPRNSE I I I I I I I IHAZARBOUS MATERIAL

INTERLOCK I #OCCUPANTSVEHIELE WEIGHT GVWR!GCWR

MATERIAL CLASS # PLACARO ID #1 - s10K LBS.

EOUIPPEO3->26KLRS. QPLACARD i I I

D BEVIEE HIT!SKIP UNIT I RELEASED2 - 10,001 - 26K LAS

1 - PASSENGER CAR 7- MRTRRCYCLE 2-WHEELED 12 -SELF CART OR-LIHD /LIAERYYEHICLE) 23-PEDESTRIAN/SEATER

2- PASSENSERYAN )MINIRAN) I - MDTORCYCLE 3-WHEELED 13 -SNDWMDIILE DR-BUS 116+ PASSENGERS) 24-WHEELCHAIR )ANYWPEI

3- SPORT UTILITYREHICLE 9- AUTOCYCLE D4-SINSLE ANITTRUCK 2R-OTHERYEHICLE 2S-OTHER NON-MOTORISTUNIT TYPE 4 - PICK UP DR -MOPED OR MOTRRIZEE 13 -SEMI-TRACTDR 21- HEAYY EQUIPMENT 26 -IICYCLE

5 - CARGRRAN BICYCLE 16-FARM EQUIPMENT 22-ANIMAL WITH RIDER CR 27 -TRAIN

6- YAN 19-OS SEATS) -ALLTERRAINYEHICLE 17 -MOTORHOME ANIMAL-DRAWN YEHICLE 99 -UNKNOWN RR HIT/SKIP

O IATY/UTA)# OFTRAILING UNITS

WASYEHICLE OPERATING IN AUTONOMOUS 0 - NOAATOMATIRN 3- CANDITIRNALAETOMATION 9- UNKNOWN

Z MODE WHEN CRASH RCCRRREDT 1- DRIRERASSISTANCE 4- HIGH AUTOMATION

L.......J 1 -YES 2- NR 9-OTHER) ENKNOW’N AUTOROMOAS 2- PARTIALAUTOMATIUN 5- FALL AUTOMATIONMBBE LEVEL

1- NINE 6- AUS—CHARYERrSOAR 11-FIRE 16-FARM 21-MAILCARRIER

0L 2- TAXI 7 - UAS — INTERCI23 12-MILITARY 17-MOWING 99-OTHER) UNKNOWN

3- ELECTRRNIC RIDE SHARING I - DOS—SHUffLE 13-POLICE OI-SNOWREMOAALSPECIALFUNCTION - SCHOOLTRANSPRRT 9- BUS—OTHER 14-PUBLIC UTILITY 09-TRWING

5- BAS—TRANSIT/COMMATER 00-AMBULANCE 15-CONSTRUCTION EQUIPMENT 20-SAFETUSERRICE PATROL

1 - NO CARGO BODYTYPE 3- REHICLETOWING ANOTHER 5- INTERMODAL CONTAINER B - POLE 02 -CONCRETE MIRER2_/ /NOTAPPLICABLE MOTORRERICLE CHASSIS 9 -CARSOTANK 03-AUTOTRANSPORTER

CARGO 2- BUS 4- LOGGING 6- CARGO RAN/ENCLOSED IDABOOY 10-FLAT BED 14-GARBAGE/REFUSE

TYPE 7- GRAIN/CHIPS/GRAAEL 11 -DAMP 99-OTHER) UNKNOWN

1 - TURN SIGNALS 4 - BRAKES T - WRRN OR SLICKTIRES 9- ROTORTROUBLE 99-OTRER/ UNKNOWNIII

VEHICLE 2- READ LAMPS 5 - STEERING I - TRAILER ERUIPRENT 10-DISABLED PROM PRIOROEFECTS 3- TAIL LAMPS 6- TIRE BLOWOUT DEFECTIRE ACCIDENT

1- INTERSECTION — MARKED 3- INTERSECTION —OTHER 6- BICYCLE LANE 9- MEDIAN/CROSSING ISLAND 02- FIRST RESPONDERL_J_J CROSSWALK 4- MIDILOCK— MARKED 7- SHOULDER) ROADSIDE 1l-DRIREWAYACCESS AT INCIDENT SCENE

NIN-MOTIRIIT 2- INTERSECTION — UNMARKEO CRRSSWALK 0 - SIDEWALK 11-SRARED USE PATHS OR 99 -OTHER) UNKNOWNLOCATION CROSSWALK 5 -TRAREL LANE—Ororo LOCATION TRAILSAT IMPADT

12 12 12

R 3 0 3 A 3

1- NON-CONTACT 0- STRAIGHTAHEAD 7- MAKING U-TURN A3-NESOTIATINSA CARRE 1R-APPROACHING

3 2- NON-COLLISION/ 2 - BACKING I - ENTERING TRAFFIC LANE 14- ENTERING OR CROSSING OR LEARING REHICLE

LJ 3-STRIKING LLJ 3 -CHANGING LANES 9- LEARINSTRAFFIC LANE SPECIFIED LOCATION 19-STANDING

ACTION 4- STRUCK PRE-ERUSH- ORERTAKINS/PASSING 10- PARKED 05 -WALKING, RUNNING, 20 -OTHER NON-MOTORIST

ACTIINS JOSSINS, PLAYING 21-STANIINS OUTSIDES - BOTH STRIKING 5- MAKING RISHTTURN 11 -SLOWING OR STOPPED6 STRUCK U - MAKING LEFTTORN INTRAFFIC 16-WORKING DISABLEIAEHICLE

9- OTHER) UNKNOWN 12-ORIRERLESS 17 -PUSHING REHICLE 99-OTHER / UNKNOWN

1- NONE 7- LEFT OF CENTER 13-IMPROPER START FROM A 17 -RISION OBSTRUCTION 20- LYING IN ROADWAY2- FAILURETO YIELD B-FOLLOWINSTOO CLOSE/ACRA PARKEO POSITION 10-OPERATING DEFECTIRE 22-NOT DISCERNIBLE

14-STOPPED OR PARKED ERAIPRENT 23-OPENING DOOR INTO3-RANREDLIGHT 9-IRPROPERLANECHANGEILLEGALLY

4- RAN STOP SIGN 00-IMPROPER PASSING 19 -LOAD SHIFTING/FALLING) ROADWAYCONTRIBUTING 15 -SWERRINGTOAROID SPILLING 99 -OTHER IMPROPERACTION5-UNSAFE SPEED 1O-DRORE OFF ROADCIRCUMSTANCES 16 -WRONG WAY 20 -IMPROPER CROSSING

6-IRPROPERTARN 12-IMPROPER BACKING

13-TOP

SEQUENCE OF EVENTS

TRAFFSC

TRAFFIC WAY FLOW

1-ONE-WAY

Z 2 - TWO-WAY

NON-COLLISION

52 I [1 - OAERTARN/ROLLORER 6- ERUIPMENT FAILURE 01 -CROSS CENTERLINE —

2 - FIRDEOPLOSION 7 - SEPARATION OF UNITS OPPOSITE DIRECTION OFTRAREL

3- IMMERSION 0 - RAN OFF ROAD RIGHT12- DOWNHILL RUNAWAY

21 I I 4-JACKKNIFE 9-RANOFFRRADLEET 13-OTHER NON-COLLISIUN5- CARSO)ERAIPMENT 10-CROSS MEDIAN 14-PEDESTRIAN

LOSSORSRIET31 I I 15-PEDALCYCLE

TRAFFIC CONTROL

1-ROUNDABOUT 4-STRPSISN

2 - SIGNAL S - YIELD SIGN

3-FLASHER 6-NOCONTROL

OF THROUGH LANESAM ROAO

16-RAILWAYREHICLE

17-ANIMAL — FARM00-ANIMAL — DEER19-ANIMAL — OTHER2O-MOTORREHICLE IN

TRANSPORT23-PARKED MOTORREHICLE

RAIL GRADE CROSSING

A - NOT INROLREI

2 - INAOLREI-ACTIAE CROSSINGI)

- INROLRED-PASSIRE CROSSING22-WORK ZONE MAINTENANCEEQUIPMENT

23-STRUCK DY FALLING,SHIFTING CARGO KRANYTHING SET IN MOTIONBYA MOTORAEHICLE

24-OTHER MORABLE OBJECT

SO-WORK ZONE MAINTENANCEEQUIPMENT

51-WALL52-BUILDING53-TUNNEL

54-OTHER FIRED OBJECT99-OTHER/UNKNOWN

I I FIRST HARMFUL EVENT _LJ MOST HARMFUL EVENT

UNIT SPEED OETECTEO SPEED

POSTED SPEED

HSYR3O4 QH1U 1/19 [76O-0D20] PAGE 4/ OFb

MOTORIST I NON-MOTORIST

INJURED TAI(EN BY

SAFETY EQUIPMENT

HSY8306 OH1M 1/19 [760-1500]

DL CLASS

EJECTION OL ENDORSEMENT

TR A PP ED

LOCAL REPORT NUMBER

I I 9i 8 R

CONDITION

ALCOHOL TEST TYPE

DRUG TEST TYPE

DRUG TEST RESULT(S)

UNIT # NAME: LAS1 FIRST, MIDDLE DATE OF BIRTH I AGEThENDER

2] /4 / 7’ /7 /4 I

ADDRESS: STREET, CITY, STATE,ZIP CONTACT PHONE - INDE AREA CODE

32 7?RP /22S72’ W,] ‘ y272 1313.013 215 I I / I

INJURIES INJURED I EMS AGENCY (NAME) I INJURED TAKENTU: MEDICAL FACILITY INARE,CITYI SAFETY EQUIPMENT ‘SEATING PISITIIN AIR BAG USAGE I EJECTIIN TRAPPED‘—‘ DOT-Coupcisur, ITAKEN I I

BY IUSED L_J MC HELMET

I I / 1

OL STATE OPERATOR LICENSE NUMBER OFFENSE CHARGED I LOCAL OFFENSE DESCRIPTION CITATION NUMBERCODE

.O#fr)??%16II:1lI*1(BDL CLASS ENDORSEMENT I RESTRICTION SELECTAPTO3 I DRIVER ALCOHOL! DRUG SUSPECTED CONDITIONTYPE I RESULt SELECTL’TCASELECT UP TO 2 I I DISTRACTED I

I BY I El ALCOHOL MARIJUANASTATUS . TYPE VALUE STATUS

________ IIII 3 I I I I I 1 I I fl 0TH ER DRUG / I I I I

UNIT N NAME: LAS1 FIRS1 MIDDLE DATE OF BIRTH AGE GENDER

0,2 KE #WADDRESS: UTREEECITSTATE,ZIP cONTA4’PHONE - IN4DE AREA CODE

/ô8U //%1Z6v/eJ44VE ,c II/,E 1,%/ 330 309 7 1, ?INJURIES INJURED I EMS AGENCY (NAME) I INJUREDTAKEN TO: MEDICAL FACILITY INAME,CITYI SAFETY EQUIPMENT SEATING PISITIIN AIR BAG USAGE I EJECTIDN1 TRAPPED

r,DOT-COMpLIANTI I

5TAKEN I I USEDBY I I L-JMC HELMET

/ , /__]

/I IDL STATE OPERATOR LICENSE NUMBER OFFENSE CHARGED I LOCAL OFFENSE DESCRIPTION CITATION NUMBER

CODE

ElI1ipIpl*1(1OL CLASS ENDORSEMENT I RESTRICTION SELECTUPTO3 DRIVER I ALCOHOL! DRUG SUSPECTED CONDITIONTYPE I RESULT SELECTUTTO4SELECT UPTO 2 I I DISTRACTED I

I BY I ALCOHOL MARIJUANASTATUS1 TYPE VALUE STATUS

I I I.II I 1 I I I I I 0TH ER DRUG / I •, I

UNIT # NAME: LAS1 FIRST MIDDLE ATEOFBIRTH AGE GENDER

C lEfR AfE AKZCV O2/y6//,9,y1,2Oj,NADDRESS: OTREET,CITY,STATE,ZIP CONTACT PHONE - ItUDE AREA CODE

2o3y,py/?AA/f’,4” 4W%c’ #‘/t’INJURIES INJURED I EMS AGENCY (NAME) INJUREDTAKENTD: MEDICAL FACILITY INAUE,CITY: SAFETY EQUIPMENT SEATING PDSDN AIR BAG USAGE I EJECTION I TRAPPED

TAKEN I USED r, DOT-COMPLIANTBY I 41 L_JMC HELMET , 2 / , , / LL

,/,

IDL STATE OPERATOR LICENSE NUMBER OFFENSE CHARGED LOCAL OFFENSE DES RIPTION CITATION NUMBER

CODEJy7yq3 333o34 AcIJilIIlI*1(1OL CLASS ENDORSEMENT RESTRICTION SELECT UPTD3 I DRIllER I ALCOHOL! DRUG SUSPECTED CONDITION iIiII7IIIJI*1

I TYPE I RESULT SELECT UPTO4I DISTRACTED ISELECT APTO 2

I BY i ALCOHOL MARIJUANAST,TATUS TYPE I VALUE STATUS

I I IIII I [ I I / OTHER DRUG .1 I I

iIPIi1lIOIlIlJi sIIi:Yr- ill41:lI Pffl[I •Pl)ll’il:,IIIIIJAtJBI(IIiIiM 114- I_*VLHII

1-FATAL 1-FRONT—LEFTSIDE 1-NOTDEPLOYED 1-CLASSA 1-ALCOHULINTERLOCKDEVICE 1-NOIDISTRACTED 1-NONEGIVEN(MOTORCYCLE 101 VERI2-SUSPECIEDSERIOUSINJURY 2-DEPLOYEDFRONI 2-CLASSI 2-CDLINTRASTATEONLY 2-MANUALLYOPERATINGAN

2- FRONT - MIDDLE ELECTRONIC COMMUNICATION3- SUSPECTED MINOR INJURY 3- DEPLOYED SIDE 3- CLASS C 3- CORRECTIVE LENSES 3 -TEST GIVEN, CONTAMINATED3- FRONT - RIGHT SIDE DEVICE ITEXTING,TYPING, SAMPLEI UNUSABLE4- POSSIBLE INJURY 4- DEPLOYED 60TH FRONT( SIDE 4- REGULAR CLASS 4- FARM WAIVER DIALING)

5- NO APPARENT INJURY 4- SECOND — LEFT SIDE (OHIO = 0) 4 -TEST GIVEN, RESULTS KNOWN5- NOT APPLICABLE 5- EXCEPT CLASS A DOS 3 -TALKING ON HANDS-FREE(MOTORCYCLE PASSENGERI9- DEPLOYMENT UNKNOWN 5- M(C MOPED ONLY 6- EXCEPT CLASS A COMMUNICATION DEVICE S -TEST GIVEN, RESULTS

5- SECOND — MIDDLE 6- NO VALID OL & CLASS B BUS 4 -TALKING ON HAND-HELDUNKNOWN

6- SECOND — RIGHT SIDEU - NOTTRANSPORTED 7- EXCEPTTRACTOR-TRAILER COMMUNICATION DEVICE(TREATEDAT SCENE 7-THIRO— LEFT SIDE 0 - INTERMEDIATE LICENSE 5- OTHER ACTIVITY WITH AN

1-NONE(MOTORCYCLE SIDE CARl2- EMS 1- NUT EJECTED H - HAZMAT RESTRICTIONS ELECTRONIC DEVICEU -THIRD — MIDDLE 2- BLOOD3- POLICE 2- PARTIALLY EJECTED M - MOTORCYCLE 9- LEARNER’S PERMIT 6- PASSENGER9 -THIRD — RIGHT SIDE RESTRICTIONS 7- OTHER DISTRACTION - URINE9-OTHER/UNKNOWN 3-TOTALLY EJECTED P- PASSENGER

10- SLEEPER SECTION 10- LIMITEITO DAYLIGHT ONLY INSIDETHE VEHICLE 4- UREATH4- NOIAPPLICABLE N -TANKEROFTRUCK CAB 11- LIMITEITO EMPLOYMENT U - OTHER DISTRACTION OUTSIDE 5- OTHER

U - MOTOR SCOOTER THE VEHICLE1-NONE USED 11-PASSENGERINOTHER

12-LIMITED—OTHERENCLOSED CARGO AREA R -THREE-WHEEL MOTORCYCLE 9-OTHER) UNKNOWN2- SHOULDER BELT ONLY USED (NON-TRAILING ONI1 BUS, 1- NOTTRAPPED S - SCHOOL BUS 13- MECHANICAL DEVICES

1- NONE3- LAP BELT ONLY USED PICK-UP WITH CAP( 2- EXTRICATED BY (SPECIAL BRAKES, HAND

4- SHOULDER & LAP UELT USED 12- PASSENGER IN UNENCLOSED MECHANICAL MEANST- DOUBLE &TRIPLE TRAILERS CONTROLS, OR OTHER 2- BLOODX -TANKER) HAZMAT ADAPTIVE DEVICESI 1 - APPARENTLY NORMAL 3- URINECARGO AREA 3-FREED BY5- CHILS RESTRAINT SYSTEM

- 14- MILITARY VEHICLES ONLY 2- PHYSICAL IMPAIRMENT 4- OTHERFORWARD FACING 13 -TRAILING UNIT NUN-MECHANICAL MEANS15- MOTOR VEHICLES WITHOUT 3 - EMOTIONAL (ED, DEPRESSED,6- CHILD RESTRAINT SYSTEM — 14- RIDING ON VEHICLE EXTERIOR

AIR BRAKES ANDRY, DISTURBEDIREAR FACING (NON-TRAILING UNITI

16-OUTSIDE MIRROR 4- ILLNESS 1-AMPHETAMINES7 - BOOSTER SEAT 15- NON-MOTORIST17- PROSTHETIC AID 5- FELt ASLEEI FAINTED, 2- BARBITURATESI - HELMET USED 99- OTHER) UNKNOWN

FATIGUED, ETC.18- OTHER 3- BENZODIAZCPINES9-PROTECTIVE PADS USED 6- ONDERTHE INFLUENCE(ELBOW, KNEES, ETC.I OF MEDICATIONS) DRUGS CANNABINUIDS

10- REFLECTIVE CLOTHING (ALCOHOL 5- COCAINE

11- LIGHTING — PEDESTRIAN 9- OTHER / UNKNOWN U - OPIATES) OPIRIDS)BICYCLEONLY 7-OTHER

99-OTHER)UNKNOWN IPAGE .çOF

LOCAL REPORT NUMBER

J382,

OCCUPANT I WITNESS ADDENDUM

I I I I

UNIT # NAME: LAS1 FIRSt MIDDLE DATE OF BIRTH AGE GENDER

:3iM2/c 21:iFiADDRESS: STREE1 CITY, STATE, ZIP CONTA T PHONE - I CLUDE AREA CODE

203 Sr,’gcs,eA’E,vr W’’z, £/w(. 2O7 7YO /21618INJURIES INJURED EMS AGENcY (NAME) INIUREDTAKEN TO: MoIcAI, FAcility (NAME, c:rv) SAFETY EQUIPMENT SEATING POSITION MR BAG USAGE EJECTIIN TRAPPED

TAKEN USED4/

ODDTCouPuANT[__30_/.z_

/UNIT # NAME: LAST, FIRST, MIDDLE DATE OF BIRTH AGE GENDER

________I I [ ) JI I It

ADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CODE

I I I I I

INJURIES INJURED EMS AGENcY (NAME) INJUREOTAKENTO: MEDICAL FACILnY (NAME, CITY) SAFETYEOUIPMENT SEATINGPISITION AIR BAG USAGE EJECTION TRAPPEDTAKEN USEI OOT-COMPLLANTBY MC HELMET

_ LJ I I) II__IJI_I

UNIT # NAME: LAD1FIRS1MIOOLE DATE OF BIRTH AGE GENDER

I I I I I I I It I

ADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CADE

I

INJURIES INJURED EMS AGENCY (NAME) INJUREOTAKENTO: MEDICAL FACILItY (NAME, CITY) SAFETYEOUIPMENT SEATING POSITIIN AIR BAG USAGE EJECTION TRAPPEDTAKEN USED DOT-COMPLIANTBY MC HELMET

I I________( [........J.......i !__i___i I L..l I

UNIT # NAME: LAST FIRST MIDDLE DATE OF BIRTH AGE GENDER

II I I I I I 1

ADDRESS: STREE1 CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CODE

INJURDES INJURED EMS AGENcY (NAME) INJUREDTAKENTO: MEDICAL FACILITY (NAME, CITY) SAFETY EQUIPMENT SEATING PISITION AIR BAG USAGETAKEN USED DOT-COMPLIANT

BY MC HELMETI

IIUI’IIIII:JJ’J

INJURIES SAFETY EQUIPMENT USED SEATING POSITION AIR BAG USAGE

INJURED TAKEN BY

EJECTION

Ii- FATAL 1- NONE USED- 1- FRONT—LEFTSIDE 1- NOTDEPLOYED

2- SUSPECTED SERIOUS INJURYVEHICLE OCCUPANT (MOTORCYCLE DRIVER)

2- DEPLOYED FRONT

3- SUSPECTED MINOR INJURY2- SHOULDER BELT ONLY USED 2- FRONT— MIDDLE

3- DEPLOYED SIDE3- FRONT-- RIGHT SIDE4- POSSIBLE INJURY

3- LAP BELT ONLY USED4- SECOND — LEFT SIDE 4- DEPLOYED BOTH

5- NOAPPARENT INJURY4- SHOULDER& LAP BELT USED (MOTORCYCLE PASSENGER) FRONT/SIDE

5- CHILD RESTRAINTSYSTEM— 5- SECOND—MIDDLE 5- NOTAPPLICABLEFORWARD FACING 6- SECOND — RIGHT SIDE 9- DEPLOYMENT UNKNOWN

1- NOT TRANSPORTED 6- CHILD RESTRAINT SYSTEM — 7- THIRD — LEFT SIDE

/TREATED AT SCENE REAR FACING (MOTORCYCLE SIDE CAR)

8- THIRD — MIDDLE2- EMS 7- BOOSTER SEAT 1- NOT EJECTED

9- THIRD — RIGHT SIDE3- POLICE 8- HELMET USED 2- PARTIALLY EJECTED

10- SLEEPER SECTION OFTRUCK CAB9- OTHER / UNKNOWN 9- PROTECTIVE PADS USED 11- PASSENGER IN OTHER ENCLOSED 3- TOTALLY EJECTED

(ELBOW, KNEES, ETC.) CARGO AREA (NON-TRAILING UNIT, 4- NOTAPPLICABLE10- REFLECTIVE CLOTHING BUS, PICK-UP WITH CAP)

12- PASSENGER IN UNENCLOSED11- LIGHTING — PEDESTRIAN CARGO AREA

/BICYCLE ONLY 1- NOTTRAPPED13- TRAILING UNIT

99- OTHER / UNKNOWN 2- EXTRICATED BY MECHANICAL14- RIDING ON VEHICLE EXTERIOR MEANS

(NON-TRAILING UNIT)

15- NON-MOTORIST 3- FREED BY NON-MECHANICALMEANS

99- OTHER/UNKNOWN

NAME: LAST FIRST MIDDLE DATE OF BIRTH I AGE GENDER

1

ADDRESS: STREE1 CITY, STATE, ZIP CONTACT PHONE- INCLUDE AREA CODE

, I I I

NAME: LAST, FIRST, MIDDLE DATE OF BIRTH AGE I GENDER

I I I I I IIl__________i_______________tIADDRESS: STREET CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CODE

I I

NAME: LAST FIRST MIDOLE DATE OF BIRTH I AGE I GENDER

( I I I L I

ADDRESS: STREET CITY, STATE, ZIP CONTACT PHONE - INCLUOE AREA CODE

I I I

TRAPPED

PAGE 0FHSY 8355 OH1P 1/19 [760-1 5001