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TRAFFIC CRASH REPORT
LOCAL INFORMATION PHOTOS TAKEN
OH -2 OH -3 OH -1P

LOCAL REPORT NUMBER *

13014176 2
CRASH DATE *

CRASH SEVERITY 1 - FATAL 2 - INJURY

3

HIT/SKIP 1 - SOLVED 2. UNSOLVED

3-

PDO

0

OTHER

PDO UNDER STATE REPORTABLE DOLLAR AMOUNT

PRIVATE REPORTING AGENCY NCIC * REPORTING AGENCY NAME * PROPERTY

05718
CITY, VILLAGE, TOWNSHIP cITY * vILLAGE* Englewood TOWNSHIP *
*

Englewood Police

NUMBER OF UNITS

UNIT IN ERROR

1

98 - ANIMAL 99 - UNKNOWN DAY OF WEEK

COUNTY *

TIME OF CRASH

Montgomery County
DEGREES/MINUTES/SECONDS LATITUDE

04/10/2013
DECIMAL DEGREES

12:22

WED

LONGITUDE

::
RoADWAY DIVISION DIVIDED UNDIVIDED N - NORTHBOUND S - SOUTHBOUND

::
DIVIDED LANE DIRECTION OF TRAVEL E - EASTBOUND W -WESTBOUND NUMBER OF THRU LANES

O R

LATITUDE

LONGITUDE

39.867823

84.292132
WA - WAY

4
LoCATION ROAD NAME

ROAD TYPES OR MILEPOST AL - ALLEY CR - CIRCLE AV - AVENUE CT - COURT BL - BOULEVARD DR - DRIVE

HE - HEIGHTS HW - HIGHWAY LA - LANE LOCATION ROAD TYPE

MP - MILEPOST PK - PARKWAY PI - PIKE

PL - PLACE RD - ROAD SQ - SQUARE

ST - STREET TE - TERRACE TL - TRAIL

US

LoCATION ROUTE NUMBER LOCATION ROUTE 00040 TYPE

LoC PREFIX N,S, E,W

ST

ROUTE TYPES IR - INTERSTATE ROUTE (INC. TURNPIKE) US - US ROUTE SR - STATE ROUTE

CR - NUMBERED COUNTY ROUTE TR - NUMBERED TOWNSHIP ROUTE REFERENCE ROAD TYPE

DISTANCE FROM REFERENCE DIR FROM REF REFERENCE REFERENCE ROUTE NUMBER REF PREFIX REFERENCE NAME (ROAD, MILEPOST, HOUSE #) MILES O N,S, ROUTE N,S, F E,W 705 TYPE 0.00 FEET E,W YARDS REFERENCE POINT USED CRASH 01 - NOT AN INTERSECTION 06 - FIVE-POINT, OR MORE 11 - RAILWAY GRADE CROSSING 1 -INTERSECTION LOCATION INTERSECTION 02 - FOUR- WAY INTERSECTIO 07 - ON RAMP 12 - SHARED-USE PATHS OR TRAILS 2 -MILE POST RELATED 03 - T-INTERSECTION 08 - OFF RAMP 99 - UNKNOWN 3 -HOUSE NUMBER 04 - Y-INTERSECTION 09 - CROSSOVER 05 - TRAFFIC CIRCLE/ ROUNDABOUT 10 - DRIVEWAY/ ALLAY ACCESS ROAD CONTOUR ROAD CONDITIONS 05 - SAND, MUD, DIRT, OIL, GRAVEL 01 - DRY PRIMARY SECONDARY 4 - CURVE GRADE 1 - STRAIGHT LEVEL 06 - WATER (STANDING, MOVING) 02 - WET 2 - STRAIGHT GRADE 9 - UNKNOWN 07 - SLUSH 03 - SNOW 3 - CURVE LEVEL 08 - DEBRIS * 04 - ICE

3

1

LOCATION OF FIRST HARMFUL EVENT 1 - ON ROADWAY 5 - ON GORE 2 - ON SHOULDE 6 - OUTSIDE TRAFFICWAY 3 - IN MEDIAN 9 - UNKNOWN 4 - ON ROADSIDE

1

1

2

09 - RUT, HOLES, BUMPS, UNEVEN PAVEMENT* 10 - OTHER 99 - UNKNOWN *SECONDARY CONDITION ONLY 7 - SEVERE CROSSWINDS 8 - BLOWING SAND,SOIL, DIRT, SNOW 9 - OTHER/UNKNOWN SCHOOL ZONE RELATED SCHOOL BUS RELATED YES, SCHOOL BUS DIRECTLY INVOLVED YES, SCHOOL BUS INDIRECTLY INVOLVED

MANNER OF CRASH COLLISION/IMPACT 1 - NOT COLLISION BETWEEN 2 - REAR-END 8 - SIDESWIPE, OPPOSITE 5 - BACKING TWO MOTOR VEHICLES DIRECTION 6 - ANGLE 3 - HEAD-ON IN TRANSPORT 7 - SIDESWIPE, -SAME DIRECTION 9 - UNKNOWN 4 - REAR-TO-REAR

WEATHER

6

2

1 - CLEAR 2 - CLOUDY 3 - FOG,SMOG, SMOKE

4 - RAIN 5 - SLEET, HAIL 6 - SNOW

ROAD SURFACE

2

1 - CONCRETE 2 - BLACKTOP, BITUMINOUS, ASPHALT 3 - BRICK/BLOCK

4 - SLAG , GRAVEL, STONE 5 - DIRT 6 - OTHER

LIGHT CONDITIONS PRIMARY

1

SECONDAR

1 - DAYLIGHT 2 - DAWN 3 - DUSK 4 - DARK - LIGHTED ROADWAY

5 - DARK - ROADWAY NOT LIGHTED 9 - UNKNOWN 6 - DARK - UNKNOWN ROADWAY LIGHTING 7 - GLARE* 8 - OTHER *SECONDARY CONDITION ONLY

wORK ZONE RELATED

wORKERS PRESENT LAW ENFORCEMENT PRESENT
(OFFICER/VEHICLE)

LAW ENFORCEMENT PRESENT
(VEHICLEONLY )

TYPE OF WORK ZONE 1 - L ANE CLOSURE 2 - LANE SHIFT/ CROSSOVER 3 - WORK ON SHOULDER OR MEDIAN

0

4 - INTERMITTENT OR MOVING WORK 5 - OTHER

LOCATION OF CRASH IN WORK ZONE 1 - BEFORE THE FIRST WORK ZONE WARNING SIGN 2 - ADVANCE WARNING AREA 3 - TRANSITION AREA

0

4 - ACTIVITY AREA 5 - TERMINATION AREA

NARRATIVE

On Wednesday, April 10, 2013 at approximately 1222 hours, Unit #1, when exiting from private property at 705 S Main St, failed to yield the right-of-way and proceeded to turn left (north) on US 40, and collided with Unit #2, which was traveling southbound on US 40 East (S Main St) in the left lane of travel.

REPORT TAKEN BY POLICE AGENCY DATE CRASHREPORTED

SUPPLEMENT (CORRECTION OR ADDITION TO AN MOTORIST
EXISTING REPORT SENT TO ODPS)

TIME CRASHREPORTED

DISPATCH TIME

ARRIVAL TIME

TIME CLEARED

OTHER INVESTIGATIONTIME

TOTAL MINUTES

04/10/2013
OFFICER'S NAME*

4/10/2013 12:22:00 PM

12:23 PM

12:23 PM
OFFICER'S BADGE NUMBER

12:52 PM
CHECKED BY

15

4

Ofc. C.M. Follick

160

Sgt. D.D. Pelkey

UNIT
UNIT NUMBER OWNER NAME: LAST, FIRST, MIDDLE ( SAME AS DRIVER ) OWNER PHONE NUMBER INC, AREA CODE

LOCAL REPORT NUMBER

13014176
( SAME AS DRIVER ) DAMAGE SCALE

1

MORITZ, CHRISTOPHER, E
SAME AS DRIVER )

DAMAGE AREA FRONT

937-520-4068

3
1 - NONE 2 - MINOR 3 - FUNCTIONAL 4 - DISABLING 9 - UNKNOWN REAR CARRIER PHONE - INCLUDE AREA CODE TRAFFICWAY DESCRIPTION 1 - T WO-WAY, NOT DIVIDED 2 - T WO-WAY, NOT DIVIDED, CONTINUOUS LEFT TURN LANE 3 - T WO-WAY, DIVIDED, UNPROTECTED(PAINTED OR GRASS >4FT.) MEDIA 4 - T WO-WAY, DIVIDED, POSITIVE MEDIANBARRIER 5 - ONE-WAY TRAFFICWAY

OWNER ADDRESS: CITY, STATE, ZIP

507 S MAIN ST APT 11, ENGLEWOOD, OH, 45322
LP STATE LICENCE PLATE NUMBER VEHICLE IDENTIFICATION NUMBER # OCCUPANTS

OH 1999

FSY3940
VEHICLE MAKE

1FAFP58S6XG198504
VEHICLE MODEL VEHICLE COLOR

1 TAN
TOWED BY

VEHICLE YEAR PROOF OF INSURANCE SHOWN

FORD
INSURANCE COMPANY

TAU
POLICY NUMBER

SAFE AUTO

OH01138327A-2

CARRIER NAME, ADDRESS, CITY, STATE, ZIP US DOT HM PLACARD ID NO. VEHICLE WEIGHT GVWR/GCWR 1 - LESS THAN OR EQUAL TO 10K LBS 2 - 10,001 TO 26,000K LBS 3 - MORE THAN 26,000K LBS. HAZARDOUS MATERIAL RELATED TYPE OF USE CARGO BODY TYPE 01 - NO CARGO BODY TYPE/NOT APPLICABL 02 - BUS/ VAN (9-15 SEATS, INC DRIVER) 03 - BUS (16+ SEATS, INC DRIVER) 04 - VEHICLE TOWING ANOTHER VEHICLE 05 - LOGGING 06 - INTERMODAL CONTAINER CHASIS 07 - CARGO VAN/ENCLOSED BOX 08 - GRAIN, CHIPS, GRAVEL

1

HM CLASS NUMBER

09 - POLE 10 - CARGO TANK 11 - FLAT BED 12 - DUMP 13 - CONCRETE MIXER 14 - AUTO TRANSPORTER 15 - GARBAGE /REFUSE 99 - OTHER/UNKNOWN

1

HIT / SKIP UNIT

NON-MOTORIST LOCATION PRIOR TO IMPACT 01 - INTERSECTION - MARKED CROSSWAL 02 - INTERSECTION - NO CROSSWALK 03 - INTERSECTION OTHER 04 - MIDBLOCK - MARKED CROSSWALK 05 - TRAVEL LANE - OTHER LOCATION 06 - BICYCLE LANE 07 - SHOULDER/ROADSIDE 08 - SIDEWALK 09 - MEDIAN/CROSSING ISLAND 10 - DRIVE WAY ACCESS 11 - SHARED-USE PATH OR TRAIL 12 - NON-TRAFFICWAY AREA 99 - OTHER/UNKNOWN

UNIT TYPE PASSENGER VEHICLES (LESS THAN 9 PASSENGERS 01 - SUB -COMPACT 02 - COMPACT 99 - UNKNOWN 03 - MID SIZE OR HIT/SKIP 04 - FULL SIZE 05 - MINIVAN 06 - SPORT UTILITY VEHICLE 07 - PICKUP 08 - VAN 09 - MOTORCYCLE 10 - MOTORIZED BICYCLE 11 - SNOWMOBILE/ATV 12 - OTHER PASSENGER VEHICLE

1
1 - PERSONAL 2 - COMMERCIAL 3 - GOVERNMENT IN EMERGENCY RESPONSE

4

MED/HEAVY TRUCKS OR COMBO UNITS > 10K LBS BUS/VAN/LIMO(9 OR MORE INCLUDING DRIVER) 13 - SINGLE UNIT TRUCK OR VAN 2AXLE, 6 TIRES 21 - BUS/VAN (9-15 SEATS, INC DRIVER) 22 - BUS (16+ SEATS, INC DRIVER) 14 - SINGLE UNIT TRUCK ; 3+ AXLES NON-MOTORIST 15 - SINGLE UNIT TRUCK / TRAILER 23 - ANIMAL WITH RIDER 16 - TRUCK/TRACTOR (BOBTAIL) 24 - ANIMAL WITH BUGGY, WAGON, SURREY 17 - TRACTOR/SEMI-TRAILER 25 - BICYCLE/PEDACYCLIST 18 - TRACTOR/DOUBLE 26 - PEDESTRIAN/SKATER 19 - TRACTOR/TRIPLES 20 - OTHER MED/HEAVY VEHICLE 27 - OTHER NON-MOTORIST

HAS HM PLACARD
ACTION 08 - LEFT SIDE 09 - LEFT FRONT 10 - TOP AND WINDOWS 11 - UNDERCARRIAGE 12 - LOAD/TRAILER 13 - TOTAL (ALL AREAS) 14 - OTHER 99 - UNKNOWN 1 - NON- CONTACT 2 - NON-COLLISION 3 - STRIKING 4 - STRUCK 5 - STRIKING/STRUCK 9 - UNKNOWN

09 - AMBULANCE SPECIAL FUNCTION01 - NONE 02 - TAXI 10 - FIRE 03 - RENTAL TRUCK (OVER 10K LBS) 11 - HIGHWAY/MAINTENANCE 04 - BUS - SCHOOL (PUBLIC OR PRIVATE) 12 - MILITARY 05 - BUS - TRANSIT 13 - POLICE 06 - BUS - CHARTER 14 - PUBLIC UTILITY 07 - BUS - SHUTTLE 15 - OTHER GOVERNMENT 08 - BUS - OTHER 16 - CONSTRUCTION EQIP.

1

17 - FARM VEHICLE MOST DAMAGED AREA 18 - FARM EQUIPMENT 01 - NONE 19 - MOTORHOME 02 - CENTER FRONT 20 - GOLF CART 03 - RIGHT FRONT 21 - TRAIN IMPACT ARE 04 - RIGHT SIDE 22 - OTHER (EXPLAIN IN NARRATIVE) 05 - RIGHT REAR 06 - REAR CENTER 07 - LEFT REAR

9 9

4

PRE- CRASH ACTIONS

6
99 - UNKNOWN

MOTORIST 01 - STRAIGHT AHEAD 02 - BACKING 03 - CHANGING LANES 04 - OVERTAKING/PASSING 05 - MAKING RIGHT TURN 06 - MAKING LEFT TURN 07 - MAKING U-TURN 08 - ENTERING TRAFFIC LANE 09 - LEAVING TRAFFIC LANE 10 - PARKED 11 - SLOWING OR STOPPED IN TRAFFIC 12 - DRIVERLESS 13 - NEGOTIATING A CURVE 14 - OTHER MOTORIST ACTIO

NON-MOTORIST 15 - ENTERING OR CROSSING SPECIFIED LOCATIO 16 - WALKING,RUNNING, JOGGING, PLAYING, CYCLING 17 - WORKING 18 - PUSHING VEHICLE 19 - APPROACHING OR LEAVING VEHICLE 20 - STANDING

21 - OTHER NON-MOTORIST ACTION

CONTRIBUTING CIRCUMSTANCE PRIMARY MOTORIST 01 - NONE 02 - FAILURE TO YIELD 03 - RAN RED LIGHT 04 - RAN STOP SIGN 05 - EXCEEDED SPEED LIMIT SECONDARY 06 - UNSAFE SPEED 07 - IMPROPER TURN 08 - LEFT OF CENTER 09 - FOLLOWED TOO CLOSELY/ACDA 99 - UNKNOWN 10 - IMPROPER LANE CHANGE /PASSING/OFF ROAD

VEHICLE DEFECTS 11 - IMPROPER BACKING 12 - IMPROPER START FROM PARKED POSITION 13 - STOPPED OR PARKED ILLEGALLY 14 - OPERATING VEHICLE IN NEGLIGENT MANNER 15 - SWERING TO AVOID (DUE TO EXTERNAL CONDITIONS) 16 - WRONG SIDE/WRONG WAY 17 - FALURE TO CONTROL 18 - VISION OBSTRUCTION 19 - OPERATING DEFECTIVE EQUIPMENT 20 - LOAD SHIFTING/FALLING/SPILLING 21 - OTHER IMPROPER ACTION NON-MOTORIST 22 - NONE 23 - IMPROPER CROSSING 24 - DARTING 25 - LYING AND/OR ILLEGALLY IN ROADWAY 26 - FALURE TO YIELD RIGHT OF WAY 27 - NOT VISIBLE (DARK CLOTHING) 28 - INATTENTIVE 29 - FAILURE TO OBEY TRAFFIC SIGNS /SIGNALS/OFFICER 30 - WRONG SIDE OF THE ROAD 31 - OTHER NON-MOTORIST ACTION 01 - TURN SIGNALS 02 - HEAD LAMPS 03 - TAIL LAMPS 04 - BRAKES 05 - STEERING 06 - TIRE BLOWOUT 07 - WORN OR SLICK TIRES 08 - TRAILER EQUIPMENT DEFECTIVE 09 - MOTOR TROUBLE 10 - DISABLED FROM PRIOR ACCIDENT 11 - OTHER DEFECTS

2

SEQUENCE OF EVENTS 1 2

20

3 Most HARMFUL EVENT

4

5

6 99 - UNKNOWN

FIRST HARMFUL EVENT

1

1

NON-COLLISION EVENTS 01 - OVERTURN/ROLLOVER 02 - FIRE/EXPLOSION 03 - IMMERSION 04 - JACKKNIFE 05 - CARGO/EQUIPMENT LOSS OR SHIFT

06 - EQUIPMENT FAILURE
(BLOWN TIRE, BRAKE FAILURE, ETC)

07 - SEPARATION OF UNITS 08 - RAN OFF ROAD RIGHT 09 - RAN OFF ROAD LEFT

10 - CROSS MEDIAN 11 - CROSS CENTER LINE OPPOSITE DIRECTION OF TRAVEL 12 - DOWNHILL RUNAWAY 13 - OTHER NON-COLLISION 41 - OTHER POST, POLE OR SUPPORT 42 - CULVART 43 - CURB 44 - DITCH 45 - EMBANKMENT 46 - FENCE 47 - MAILBOX 1 - NORTH 2 - SOUTH 3 - EAST 4 - WEST 48 - TREE 49 - FIRE HYDRANT 50 - WORK ZONE MAINTENANCE EQUIPMENT 51 - WALL, BUILDING, TUNNEL 52 - OTHER FIXED OBJECT

COLLISION WITH PERSON, VEHICLE OR OBJECT NOT FIXED 14 - PEDESTRIAN 21 - PARKED MOTOR VEHICLE 15 - PEDALCYCLE 22 - WORK ZONE MAINTENANCE EQUIPMENT 16 - RAILWAY VEHICLE (TRAIN, ENGINE) 23 - STRUCK BY FALLING, SHIFTING CARGO 17 - ANIMAL - FARM OR ANYTHING SET IN MOTION BY A 18 - ANIMAL - DEER MOTOR VEHICLE 19 - ANIMAL -OTHER 24 - OTHER MOVABLE OBJECT 20 - MOTOR VEHICLE IN TRANSPORT UNIT SPEED POSTED SPEED TRAFFIC CONTROL

COLLISION WITH FIXED, OBJECT 25 - IMPACT ATTENUATOR/CRASH CUSHION - MEDIAN CABLE BARRIER 33 26 - BRIDGE OVERHEAD STRUCTURE 26 - MEDIAN GUARDRAIL BARRIER 27 - BRIDGE PIER OR ABUTMENT 35 - MEDIAN CONCRETE BARRIER 28 - BRIDGE PARAPET 36 - MEDIAN OTHER BARRIER 29 - BRIDGE RAIL 37 - TRAFFIC SIGN POST 30 - GUARDRAIL FACE 38 - OVERHEAD SIGN POST 31 - GUARDRAILEND 39 - LIGHT/LUMINARIES SUPPORT 32 - PORTABLE BARRIER 40 - UTILITY POLE UNIT DIRECTION 07 - RAILROAD CROSSBUCKS 08 - R AILROAD FLASHERS 09 - R AILROAD GATES 10 - COSTRUCTION BARRICADE 11 - PERSON (FLAGGER, OFFICER 12 - PAVEMENT MARKINGS 13 - CROSSWALK LINES 14 - W ALK/DON'T WALK 15 - O THER 16 - NOT REPORTED FROM

10
STATED ESTIMATED

35

1

01 - NO CONTROLS 02 - S TOP SIGN 03 - YIELD SIGN 04 - TRAFFIC SIGNAL 05 - TRAFFIC FLASHERS 06 - SCHOOL ZONE

4

TO

1

5 - NORTHEAST 6 - NORTHWEST 7 - SOUTHEAST 8 - SOUTHWEST

9 - UNKNOWN

UNIT
UNIT NUMBER OWNER NAME: LAST, FIRST, MIDDLE ( SAME AS DRIVER ) OWNER PHONE NUMBER INC, AREA CODE

LOCAL REPORT NUMBER

13014176
( SAME AS DRIVER ) DAMAGE SCALE

2

WHITE, JANET, SHIRLEY
SAME AS DRIVER )

DAMAGE AREA FRONT

3
1 - NONE 2 - MINOR 3 - FUNCTIONAL 4 - DISABLING TOWED BY 9 - UNKNOWN REAR CARRIER PHONE - INCLUDE AREA CODE TRAFFICWAY DESCRIPTION 1 - T WO-WAY, NOT DIVIDED 2 - T WO-WAY, NOT DIVIDED, CONTINUOUS LEFT TURN LANE 3 - T WO-WAY, DIVIDED, UNPROTECTED(PAINTED OR GRASS >4FT.) MEDIA 4 - T WO-WAY, DIVIDED, POSITIVE MEDIANBARRIER 5 - ONE-WAY TRAFFICWAY

OWNER ADDRESS: CITY, STATE, ZIP

2338 TELEGRAPH AVE, BERKELEY, CA, 94704
LP STATE LICENCE PLATE NUMBER VEHICLE IDENTIFICATION NUMBER # OCCUPANTS

OH 2008

6YKL207
VEHICLE MAKE

1J8GP28K98W206902
VEHICLE MODEL VEHICLE COLOR

1

VEHICLE YEAR PROOF OF INSURANCE SHOWN

JEEP
INSURANCE COMPANY

OTH
POLICY NUMBER

STATE FARM

7747682-D12-35

CARRIER NAME, ADDRESS, CITY, STATE, ZIP US DOT HM PLACARD ID NO. VEHICLE WEIGHT GVWR/GCWR 1 - LESS THAN OR EQUAL TO 10K LBS 2 - 10,001 TO 26,000K LBS 3 - MORE THAN 26,000K LBS. HAZARDOUS MATERIAL RELATED TYPE OF USE CARGO BODY TYPE 01 - NO CARGO BODY TYPE/NOT APPLICABL 02 - BUS/ VAN (9-15 SEATS, INC DRIVER) 03 - BUS (16+ SEATS, INC DRIVER) 04 - VEHICLE TOWING ANOTHER VEHICLE 05 - LOGGING 06 - INTERMODAL CONTAINER CHASIS 07 - CARGO VAN/ENCLOSED BOX 08 - GRAIN, CHIPS, GRAVEL

1

HM CLASS NUMBER

09 - POLE 10 - CARGO TANK 11 - FLAT BED 12 - DUMP 13 - CONCRETE MIXER 14 - AUTO TRANSPORTER 15 - GARBAGE /REFUSE 99 - OTHER/UNKNOWN

1

HIT / SKIP UNIT

NON-MOTORIST LOCATION PRIOR TO IMPACT 01 - INTERSECTION - MARKED CROSSWAL 02 - INTERSECTION - NO CROSSWALK 03 - INTERSECTION OTHER 04 - MIDBLOCK - MARKED CROSSWALK 05 - TRAVEL LANE - OTHER LOCATION 06 - BICYCLE LANE 07 - SHOULDER/ROADSIDE 08 - SIDEWALK 09 - MEDIAN/CROSSING ISLAND 10 - DRIVE WAY ACCESS 11 - SHARED-USE PATH OR TRAIL 12 - NON-TRAFFICWAY AREA 99 - OTHER/UNKNOWN

UNIT TYPE PASSENGER VEHICLES (LESS THAN 9 PASSENGERS 01 - SUB -COMPACT 02 - COMPACT 99 - UNKNOWN 03 - MID SIZE OR HIT/SKIP 04 - FULL SIZE 05 - MINIVAN 06 - SPORT UTILITY VEHICLE 07 - PICKUP 08 - VAN 09 - MOTORCYCLE 10 - MOTORIZED BICYCLE 11 - SNOWMOBILE/ATV 12 - OTHER PASSENGER VEHICLE

1
1 - PERSONAL 2 - COMMERCIAL 3 - GOVERNMENT IN EMERGENCY RESPONSE

6

MED/HEAVY TRUCKS OR COMBO UNITS > 10K LBS BUS/VAN/LIMO(9 OR MORE INCLUDING DRIVER) 13 - SINGLE UNIT TRUCK OR VAN 2AXLE, 6 TIRES 21 - BUS/VAN (9-15 SEATS, INC DRIVER) 22 - BUS (16+ SEATS, INC DRIVER) 14 - SINGLE UNIT TRUCK ; 3+ AXLES NON-MOTORIST 15 - SINGLE UNIT TRUCK / TRAILER 23 - ANIMAL WITH RIDER 16 - TRUCK/TRACTOR (BOBTAIL) 24 - ANIMAL WITH BUGGY, WAGON, SURREY 17 - TRACTOR/SEMI-TRAILER 25 - BICYCLE/PEDACYCLIST 18 - TRACTOR/DOUBLE 26 - PEDESTRIAN/SKATER 19 - TRACTOR/TRIPLES 20 - OTHER MED/HEAVY VEHICLE 27 - OTHER NON-MOTORIST

HAS HM PLACARD
ACTION 08 - LEFT SIDE 09 - LEFT FRONT 10 - TOP AND WINDOWS 11 - UNDERCARRIAGE 12 - LOAD/TRAILER 13 - TOTAL (ALL AREAS) 14 - OTHER 99 - UNKNOWN 1 - NON- CONTACT 2 - NON-COLLISION 3 - STRIKING 4 - STRUCK 5 - STRIKING/STRUCK 9 - UNKNOWN

09 - AMBULANCE SPECIAL FUNCTION01 - NONE 02 - TAXI 10 - FIRE 03 - RENTAL TRUCK (OVER 10K LBS) 11 - HIGHWAY/MAINTENANCE 04 - BUS - SCHOOL (PUBLIC OR PRIVATE) 12 - MILITARY 05 - BUS - TRANSIT 13 - POLICE 06 - BUS - CHARTER 14 - PUBLIC UTILITY 07 - BUS - SHUTTLE 15 - OTHER GOVERNMENT 08 - BUS - OTHER 16 - CONSTRUCTION EQIP.

1

17 - FARM VEHICLE MOST DAMAGED AREA 18 - FARM EQUIPMENT 01 - NONE 19 - MOTORHOME 02 - CENTER FRONT 20 - GOLF CART 03 - RIGHT FRONT 21 - TRAIN IMPACT ARE 04 - RIGHT SIDE 22 - OTHER (EXPLAIN IN NARRATIVE) 05 - RIGHT REAR 06 - REAR CENTER 07 - LEFT REAR

3 3

3

PRE- CRASH ACTIONS

1
99 - UNKNOWN

MOTORIST 01 - STRAIGHT AHEAD 02 - BACKING 03 - CHANGING LANES 04 - OVERTAKING/PASSING 05 - MAKING RIGHT TURN 06 - MAKING LEFT TURN 07 - MAKING U-TURN 08 - ENTERING TRAFFIC LANE 09 - LEAVING TRAFFIC LANE 10 - PARKED 11 - SLOWING OR STOPPED IN TRAFFIC 12 - DRIVERLESS 13 - NEGOTIATING A CURVE 14 - OTHER MOTORIST ACTIO

NON-MOTORIST 15 - ENTERING OR CROSSING SPECIFIED LOCATIO 16 - WALKING,RUNNING, JOGGING, PLAYING, CYCLING 17 - WORKING 18 - PUSHING VEHICLE 19 - APPROACHING OR LEAVING VEHICLE 20 - STANDING

21 - OTHER NON-MOTORIST ACTION

CONTRIBUTING CIRCUMSTANCE PRIMARY MOTORIST 01 - NONE 02 - FAILURE TO YIELD 03 - RAN RED LIGHT 04 - RAN STOP SIGN 05 - EXCEEDED SPEED LIMIT SECONDARY 06 - UNSAFE SPEED 07 - IMPROPER TURN 08 - LEFT OF CENTER 09 - FOLLOWED TOO CLOSELY/ACDA 99 - UNKNOWN 10 - IMPROPER LANE CHANGE /PASSING/OFF ROAD

VEHICLE DEFECTS 11 - IMPROPER BACKING 12 - IMPROPER START FROM PARKED POSITION 13 - STOPPED OR PARKED ILLEGALLY 14 - OPERATING VEHICLE IN NEGLIGENT MANNER 15 - SWERING TO AVOID (DUE TO EXTERNAL CONDITIONS) 16 - WRONG SIDE/WRONG WAY 17 - FALURE TO CONTROL 18 - VISION OBSTRUCTION 19 - OPERATING DEFECTIVE EQUIPMENT 20 - LOAD SHIFTING/FALLING/SPILLING 21 - OTHER IMPROPER ACTION NON-MOTORIST 22 - NONE 23 - IMPROPER CROSSING 24 - DARTING 25 - LYING AND/OR ILLEGALLY IN ROADWAY 26 - FALURE TO YIELD RIGHT OF WAY 27 - NOT VISIBLE (DARK CLOTHING) 28 - INATTENTIVE 29 - FAILURE TO OBEY TRAFFIC SIGNS /SIGNALS/OFFICER 30 - WRONG SIDE OF THE ROAD 31 - OTHER NON-MOTORIST ACTION 01 - TURN SIGNALS 02 - HEAD LAMPS 03 - TAIL LAMPS 04 - BRAKES 05 - STEERING 06 - TIRE BLOWOUT 07 - WORN OR SLICK TIRES 08 - TRAILER EQUIPMENT DEFECTIVE 09 - MOTOR TROUBLE 10 - DISABLED FROM PRIOR ACCIDENT 11 - OTHER DEFECTS

1

SEQUENCE OF EVENTS 1 2

20

3 Most HARMFUL EVENT

4

5

6 99 - UNKNOWN

FIRST HARMFUL EVENT

1

1

NON-COLLISION EVENTS 01 - OVERTURN/ROLLOVER 02 - FIRE/EXPLOSION 03 - IMMERSION 04 - JACKKNIFE 05 - CARGO/EQUIPMENT LOSS OR SHIFT

06 - EQUIPMENT FAILURE
(BLOWN TIRE, BRAKE FAILURE, ETC)

07 - SEPARATION OF UNITS 08 - RAN OFF ROAD RIGHT 09 - RAN OFF ROAD LEFT

10 - CROSS MEDIAN 11 - CROSS CENTER LINE OPPOSITE DIRECTION OF TRAVEL 12 - DOWNHILL RUNAWAY 13 - OTHER NON-COLLISION 41 - OTHER POST, POLE OR SUPPORT 42 - CULVART 43 - CURB 44 - DITCH 45 - EMBANKMENT 46 - FENCE 47 - MAILBOX 1 - NORTH 2 - SOUTH 3 - EAST 4 - WEST 48 - TREE 49 - FIRE HYDRANT 50 - WORK ZONE MAINTENANCE EQUIPMENT 51 - WALL, BUILDING, TUNNEL 52 - OTHER FIXED OBJECT

COLLISION WITH PERSON, VEHICLE OR OBJECT NOT FIXED 14 - PEDESTRIAN 21 - PARKED MOTOR VEHICLE 15 - PEDALCYCLE 22 - WORK ZONE MAINTENANCE EQUIPMENT 16 - RAILWAY VEHICLE (TRAIN, ENGINE) 23 - STRUCK BY FALLING, SHIFTING CARGO 17 - ANIMAL - FARM OR ANYTHING SET IN MOTION BY A 18 - ANIMAL - DEER MOTOR VEHICLE 19 - ANIMAL -OTHER 24 - OTHER MOVABLE OBJECT 20 - MOTOR VEHICLE IN TRANSPORT UNIT SPEED POSTED SPEED TRAFFIC CONTROL

COLLISION WITH FIXED, OBJECT 25 - IMPACT ATTENUATOR/CRASH CUSHION - MEDIAN CABLE BARRIER 33 26 - BRIDGE OVERHEAD STRUCTURE 26 - MEDIAN GUARDRAIL BARRIER 27 - BRIDGE PIER OR ABUTMENT 35 - MEDIAN CONCRETE BARRIER 28 - BRIDGE PARAPET 36 - MEDIAN OTHER BARRIER 29 - BRIDGE RAIL 37 - TRAFFIC SIGN POST 30 - GUARDRAIL FACE 38 - OVERHEAD SIGN POST 31 - GUARDRAILEND 39 - LIGHT/LUMINARIES SUPPORT 32 - PORTABLE BARRIER 40 - UTILITY POLE UNIT DIRECTION 07 - RAILROAD CROSSBUCKS 08 - R AILROAD FLASHERS 09 - R AILROAD GATES 10 - COSTRUCTION BARRICADE 11 - PERSON (FLAGGER, OFFICER 12 - PAVEMENT MARKINGS 13 - CROSSWALK LINES 14 - W ALK/DON'T WALK 15 - O THER 16 - NOT REPORTED FROM

25
STATED ESTIMATED

35

1

01 - NO CONTROLS 02 - S TOP SIGN 03 - YIELD SIGN 04 - TRAFFIC SIGNAL 05 - TRAFFIC FLASHERS 06 - SCHOOL ZONE

1

TO

2

5 - NORTHEAST 6 - NORTHWEST 7 - SOUTHEAST 8 - SOUTHWEST

9 - UNKNOWN

MOTORIST / NON-MOTORIST / OCCUPANT
UNIT NUMBER NAME: LAST, FIRST, MIDDLE DATE
OF

LOCAL REPORT NUMBER

13014176
BIRTH AGE GENDER

1
MOTORIST/NON-MOTORIST

MORITZ, CHRISTOPHER, E

12/31/1975
CONTACT PHONE

37
- INCLUDE AREA CODE

F

F - FEMALE M - MALE

ADDRESS, CITY, STATE, ZIP

507 S MAIN ST APT 11, ENGLEWOOD, OH, 45322
INJURIES INJURED TAKEN BY EMS AGENCY MEDICAL FACILITY INJURED TAKEN TO SAFETY EQUIPMENT USED

937-520-4068
DOT COMPLIANT SEATING POSITION AIR BAG USAGE EJECTION TRAPPED MOTORCYCLE HELMET

1
OL STATE

1
OPERATOR LICENCE NUMBER OL CLASS

4

1

1

1

1

OH 432.20

RT279503
( LOCAL CODE)

4

NO VALID DL

M/C END

CONDITION

ALCOHOL/DRUG SUSPECTED ALCOHOL TEST STATUS ALCOHOL TEST TYPE ALCOHOL TEST VALUE DRUG TEST STATUS DRUG TEST TYPE

1

1

1
201388

1
CITATION NUMBER

000
HANDS-FREE DEVICE USED
OF

1

1
DRIVER DISTRACTED BY

OFFENSE CHARGED

OFFENSE DESCRIPTION

RIGHT-OF-WAY - PRIV. WHITE, JANET, SHIRLEY

1
GENDER

UNIT NUMBER NAME: LAST, FIRST, MIDDLE

DATE

BIRTH

AGE

2
MOTORIST/NON-MOTORIST

12/20/1989
CONTACT PHONE

23
- INCLUDE AREA CODE

F

F - FEMALE M - MALE

ADDRESS, CITY, STATE, ZIP

2338 TELEGRAPH AVE, BERKELEY, CA, 94704
INJURIES INJURED TAKEN BY EMS AGENCY MEDICAL FACILITY INJURED TAKEN TO SAFETY EQUIPMENT USED

1
OL STATE

1
OPERATOR LICENCE NUMBER OL CLASS

4

DOT COMPLIANT SEATING POSITION AIR BAG USAGE EJECTION TRAPPED MOTORCYCLE HELMET

1

1

1

1

CA

F5036686
( LOCAL CODE)

4

NO VALID DL

M/C END

CONDITION

ALCOHOL/DRUG SUSPECTED ALCOHOL TEST STATUS ALCOHOL TEST TYPE ALCOHOL TEST VALUE DRUG TEST STATUS DRUG TEST TYPE

1

1

1

1
CITATION NUMBER

000
HANDS-FREE DEVICE USED

1

1
DRIVER DISTRACTED BY

OFFENSE CHARGED

OFFENSE DESCRIPTION

1

INJURIES 1 - NO INJURY / NONE REPORTE 2 - POSSIBLE 3 - NON-INCAPACITATING 4 - INCAPACITATING 5 - FATAL

INJURED TAKEN BY 1 - NOT TRANSPORTED / TREATED AT SCENE 2 - EMS 3 - POLICE 4 - OTHER 9 - UNKNOWN

SAFETY EQUIPMENT USED MOTORIST 01 - NONE USED - VEHICLE OCCUPANT 02 - S HOULDER BELT ONLY USED 03 - LAP BELT ONLY USED 04 - S HOULDER AND LAP BELT ONLY USED

99 - UNKNOWN SAFETY EQUIPMENT NON-MOTORIST 05 - CHILD RESTRAINT SYSTEM-FORWARD FACING 06 - CHILD RESTRAINT SYSTEM-REAR FACING 07 - BOOSTER SEAT 08 - HELMET USED 09 - NONE USED 10 - HELMET USED 11 - PROTECTIVE PADS USED
(ELBOWS, KNEES, ETC)

12 - REFLECTIVE COATING 13 - LIGHTING 14 - OTHER

SEATING POSITION 01 - FRONT - LEFT SIDE (MOTORCYCLE DRIVER) 02 - FRONT - MIDDLE 03 - FRONT - RIGHT SIDE 04 - SECOND - LEFT SIDE (MOTORCYCLE PASSENGER) 05 - SECOND - MIDDLE 06 - SECOND - RIGHT SIDE EJECTION TRAPPED 07 - THIRD - LEFT SIDE (MOTORCYCLE SIDE CAR) 08 - THIRD - MIDDLE 09 - THIRD - RIGHT SIDE 10 - SLEEPER SECTION OF CAB (TRUCK) 11 - PASSENGER IN OTHER ENCLOSED CARGO AREA
(NON-TRAILING UNIT SUCH AS A BUS, PICK-UP WITH CAP)

AIR BAG USAGE 12 - PASSENGER IN UNENCLOSED CARGO AREA 13 - TRAILING UNIT 14 - RIDING ON VEHICLE EXTERIOR (NON-TRAILING UNIT) 15 - NON-MOTORIST 16 - OTHER 99 - UNKNOWN 1 - NOT DEPLOYED 2 - DEPLOYED FRONT 3 - DEPLOYED SIDE 4 - DEPLOYED BOTH FRONT/SIDE 5 - NOT APPLICABLE 9 - DEPLOYMENT UNKNOWN ALCOHOL/DRUG SUSPECTED 5 - FELL ASLEEP, FAINTED, FATIGUE 6 - UNDER THE INFLUENCE OF MEDICATIONS, DRUGS, ALCOHOL 7 - OTHER 1 - NONE 2 - YES - ALCOHOL SUSPECTED 3 - YES -HBD NOTIMPAIRED 4 - YES -DRUGS SUSPECTED 5 - YES -ALCOHOL AND DRUGS SUSPECTED

OPERATOR LICENSE CLASS 1 - CLASS A 2 - CLASS B 3 - CLASS C 4 - REGULAR CLASS (OHIO IS "D") 5 - MC/MOPED ONLY ALCOHOL TEST TYPE 1 - NONE 2 - BLOOD 3 - URINE 4 - BREATH 5 - OTHER DRUG TEST STATUS

CONDITION 1 - APPARENTLY NORMAL 2 - PHYSICAL IMPAIRMENT 3 - EMOTIONL (DEPRESSED, ANGRY, DISTURBE 4 - ILLNESS

1 - NOT EJECTED 1 - NOT TRAPPED 2 - TOTALLY EJECTED 2 - EXTRICATED BY 3 - PARTIALLY EJECTED MECHANICAL MEANS 4 - NOT APPLICABLE 3 - EXTRICATED BY NON-MECHANICAL MEANS ALCOHOL TEST STATUS 1 - NONE GIVEN 2 - TEST REFUSED 3 - TEST GIVEN, CONTAMINATED SAMPLE/UNUSABL 4 - TEST GIVEN, RESULTS KNOWN 5 - TEST GIVEN, RESULTS UNKNOWN UNIT NUMBER NAME: LAST, FIRST, MIDDLE

DRUG TEST TYPE 1 - NONE 2 - BLOOD 3 - URINE 4 - BREATH 5 - OTHER

DRIVER DISTRACTED BY 1 - NO DISTRACTION REPORTED 2 - PHONE 3 - TEXTING /EMAILING 4 - ELCTRONIC COMMUNICATION DEVICE 5 - OTHER ELECTRONIC DEVICE
(NAVIGATION DEVICE, RADIO, DVD)

1 - NONE GIVEN 2 - TEST REFUSED 3 - TEST GIVEN, CONTAMINATED SAMPLE/UNUSABL 4 - TEST GIVEN, RESULTS KNOWN 5 - TEST GIVEN, RESULTS UNKNOWN

6 - OTHER INSIDE THE VEHICLE 7 - EXTERNAL DISTRACTION

DATE

OF

BIRTH

AGE

GENDER F - FEMALE M - MALE

OCCUPANT

ADDRESS, CITY, STATE, ZIP

CONTACT PHONE

- INCLUDE AREA CODE

INJURIES

INJURED TAKEN BY EMS AGENCY

MEDICAL FACILITY INJURED TAKEN TO

SAFETY EQUIPMENT USED

DOT COMPLIANT MOTORCYCLE HELMET DATE
OF

SEATING POSITION AIR BAG USAGE EJECTION TRAPPED

UNIT NUMBER NAME: LAST, FIRST, MIDDLE

BIRTH

AGE

GENDER F - FEMALE M - MALE

OCCUPANT

ADDRESS, CITY, STATE, ZIP

CONTACT PHONE

- INCLUDE AREA CODE

INJURIES

INJURED TAKEN BY EMS AGENCY

MEDICAL FACILITY INJURED TAKEN TO

SAFETY EQUIPMENT USED

DOT COMPLIANT MOTORCYCLE HELMET

SEATING POSITION AIR BAG USAGE EJECTION TRAPPED

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