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TR9501-CS 970930T~AS p~f_~_. OFFICER'S. ACCIDENT REPORT PLACE WHERE ACCIDENT OCCURRED~ cou.TY IF ACCIOENT WAS OLJTSIDE CITY LIMITS, INOICATE DISTANCE FROM NEAREST TOWN ROAD ON WHICH ACCIDENT OCCURRED ~)0 BLOCK NUMBER INTERSECTING STREET OR RR X'ING NUMBER NOT AT INTERSECTION DATE OF ACmDE"T ©q - OI BLOCK NUMBER ST-3 (Elf. 1/1/~.~ MILES hAIL TO: ACCIDENT RECORDS, TEXAS DEl* ~ENT OF PUBLIC SAFETY, PO BOX 4087, AUSTIN TX 78773-0001 C,TY OR TOW. C~kl NORTH S E W OF SHOW ONLY IF INSIDE CITY LIMITS CITY OR TOWN DO NOT WRITE IN THIS SPACE ~-~ '~ / ~k CONSTR. [] YES SPEED L.~ V_~C ~' (~',~ ZONE [~NO LIMIT ~ STREET OR RDAO/NAME ~ ROUTE NUMBER OR STREET CORE CONSTR. [] YES SPEED ZONE [] NO LIMIT __ STREET OR RDAO NAME ROUTE NUMBER OR STREET COOE N~ SHOW M LEPOST OR NEAREST INTERSECTING NUMBERED HIGHWAY. MI. E W IF NONE. SHOW NEAREST INTER~ECTINO STREET OR REFERENCE PO NT. I WEEK ~J~"~x HOUR ~°~00 RM. OR MIDNIGHT, SO STATE LOC. COOE SEVERITY FAT. REC, DR. REC. DPS NO. UNIT NO. 1 - MOTOR VEHICLE YEA, COLD. Go/ MOOEL qL .MAKE DRIVER'S NAME ~J3~',~ f%0~ '~O~r-i ~.~--. ~ FIRST MIDDLE LICENSE i ~ STATE NUMBER ' C~SS/TY~ SPECIMEN TAKEN (ALCOHOL/DRUG ANALYSIS) 1-BREATH 2-B~OD 3-OTHER A-NONE 5-REFUSED LESSEE ~ OWNER ~ '~ NAME (ALWAYS SHOW LESSEE IF L~ED, OTHERWISE SHOW OWNER} ~' ~'~L.'~.~.c~ ~ ~/%~ ~ ~HE)c~ IF BODY STYLE = VAN OR BUS, INDICATE SEATING CAPACITY -/- VEH IDENT NO NAMEMODEL ~j~j BODY ~O~Y'L PLATELICENSE qB ~ ~G-I~q~ STYLE Y~R ~ATE NUMBER PHONE ADDRES~ (STREW, CI~, ~, ZIP) . 008 0~-0~-~1 RACE hq SEX ~ OCCUPATION ~O&~ MO UY YEAR PEACE OFFICER, EMS DRIVER, ALCOHOL/DRUG ANALYSIS RESULT FIRE FIGHTER ON EMERGENCY? ADDRESS (STREET, CITY, STATE, ZIP) [] YES ~ NO LIABILITY ~ YES INSURANCE LJNO ~diP--C' T~%. INSURANCE COMPANY NAME POLICY NUMBER VEHICLE DAMAGE RATING UNIT NO, 2 TOWED ~ PEDESTRIAN [] OTHER [] YEAR COLOR MODEL & MAKE , DRIVER'S NAME DRIVER'S LAST FIRST MOTOR VEHICLE ~ TRAIN [] PEDALCYCLIST [] VEH IDENT NO MODEL NAME BODY STYLE ADORESS (STREET, CITY, STATE, ZiP) IF BODY STYLE = VAN OR BUS, INDICATE SEATING CAPACITY LICENSE DOB RACE SEX __ OCCUPATION MO DAY yEAR MIDDLE ALCOHOL/DRUG ANALYSIS RESULT LICENSE PLATE YEAR STATE NUMBER PHONE NUMBER PEACE OFFICER, EMS DRIVER, FIRE FIGHTER ON EMERGENCY? [] YES [] NO STATE NUMBER CLASS/TYPE SPECIMEN TAKEN (ALCOHOL/DRUG ANALYSIS) ~ 1-BREATH 2-BLOOD 3-OTHER 4-NONE 5-REFUSED LESSEE ~ OWNER ~ NAMEIALWAYS SHOW LESSEE IF LEASED, OTHERWISE SHOW OWNER} LIABILITY [] YES INSURANCE [] NO INSURANCE COMPANY NAME ADDRESS {~iH~i, CITY, STATE, ZIP) P~UCY NUMBER VEHICLE DAMAGE RATING DAMAGE TO PROPERTY OTHER THAN VEHICLES OBJECT - F NAME AND ADDRI~S~ (STREST, CITY, STATE. ZiP) OF pWNER U ' FEET FROM CURB DAMAGE ESTIMATE LIGHT [~i CONDITION 1-DAYLIGHT 2-DAWN 3-OARK-NOT LIGHTED 4-DARK-UGHTED 5-DUSK WEATHER ~ 1-CLEAR/CLOUDY 6-SMOKE 2-RAINING 7-SLEETING 3-SNOWING B-HIGH WINDS 4-FOG 9-OTHER 5-BLOWING DUST SURFACE CONDITION 1-DRY 2-WET 13-MUDDY 4-SNOWY/ICY 5-OTHER TYPE ROAD SURFACE 1-BLACKTOP 2-CONCRETE 3-GRAVEL 4oSHELL 5oDIRT 6-OTHER DESCRIBE ROAD CONDITIONS (INVESTIGATOR'S OPINION) IN YOUR OPINION, DID THIS ACCIDENT RESULT IN AT LEAST $500.00 DAMAGE TO ANY ONE PERSON'S PROPERTY? ~ YES [] NO CHARGES FILED NAME C.A.GE $ff C,TAT, O. .UMBE" 5,Sg~O CITATION CHARGE NUMBER TIME NOTIFIED OF ACCIDENT OCtrOI -~-7 1I 5gf~ u .OW DATE HOUR I..EO o..re.TED .AME o~ INVESTIGATOR ,%~ ~. SIGNATURE OF INVESTIGAtoR ~ ~. ~.,~,.~ TIME ARRIVED AT C~d~'-OI-9 7 I~-'01 ? M SCENE OF ACCIDENT DATE HOUR DATE REPORT MADE O~-(~°~~ IS RE.AT COMPL~E ~YES ~ NO DEPARTMmT~O~ ~D DIST./AR~ ~ / ~ ~0 ~L ~ / SVC. ~ ? 7- ~ ~ PB, ot ~ S.W. Buses. III ~9 T I SOLICITATION (SON INDICATES PERSON'S OESIRE TO RECEIVE CONTACT FROM PERSONS SEEKING PROFESSIONAL EMPLOYMENT AS/FOR AN ATTORNEY, CHIROPRACTOR. PHYSICIAN, SURGEON, PRIVATE INVESTIGATOR. OR ANY OTHER PERSON REDISTERED ORLICENSED RY A HEALTH CARE REGULATORY AGENCY. Y--O.K. TO SOLICIT N--HO SOLICITATION CODE FOR TYPE RESTRAINT USED - NOT APPUCABLE A - SEATBELT & SHOULDER STRAP - YES B - SEATRELT & NO SHOULDER STRAP - NO C - CHILD RESTRAINT - PRSTIALLY E - SHOULDER STRAP ONLY · UNK N - HONE I HELMET USE , AIRBAG CODE Iu - UNK IF DEPLOYED 3 - ~RN-UNK IF DATRA~ED UNIT NO. 1 TOWED DUE VEH CLE ~ A , '~ - ~ [ TO DAMAGE REMOVED TO ~(V & ~.. OAMAGE _ ' ' , - · ,A,,,G FC 5 laY- [].o .Y COMPLETE ALL DATA ON ALL' OCCUPANTS' NAMES, ~SITtONS, RESTRAINTS USED, ETC.; HOWLER, OCCUPANT'S ] IT IS NOT NECESSARY TO SHOW ADORESSES UNLESS KILLED OR INJUREO. ~SITION J NAME (~ST NAME FIRST) ADDRESS (STREW, CITY, STATE, ZIP) DRIVER SEE FRONT CORE FOR (COMPLETE IF CASUALTIES NOT/ INJURY SEVERITY I IN MOTOR VEHICLE) Ko KILLED I 1 - BREATH A* INCAI~CITATIN6 iNJURY 2- BLDDO Do NON INCAPACITATING 3- OTHER C - POSSIBLE INJURY 4 - NONE N - NUT INJUREI~ 5 - REFUGED ISOL I"'= I" I'ED4"E 4 .E I SEN I'= UNIT NO. 2 (COMPLETE ONLY IF UNIT TOWED OUE VEHICLE DAMAGE NO. 2 WAS A MOTOR VEHICLE) TO DAMAGE REMOVED TO RATING [] YES [] NO BY COMPLETE ALL DATA ON ALL OCCUPANTS' NAMES, POSITIONS, RESTRAINTS USED, ETC.; HOWEVER, OCCUPANT'S J IT IS NOT NECESSARY TO SHOW ADDRESSES UNLESS KILLED OR INJURED. POSITION J NAME (LAST NAME FIRST) ADDRESS (STREET, CITY, STATE, ZIP) DRIVER SEE FRONT COMPLETE IF CASUALTIES NOT IN MOTOR VEHICLE CASUALTY NAME (LAST NAME FIRST) CASUALTY ADDRESS (STREET, CITY, STATE, ZIP) DISPOSITION OF KILLED AND INJURED TEM NUMBERS TAKEN TO BY COMPLETE THIS SECTION IF PERSON KILLED ITEM NUMBER DATE OF DEATH N~IFIED AT SCENE INC. DRIV~ ITEM NUMBER I DATE OF D~TH F TIME OF D~TH INVESTIGATOR'S NARRMIVE OPINION OF WHM HAPPENED (~CH ADDITIONAL SHEETS IF NECES~RY) P~..Df..~P~..~!..~..bD~..9~..~9~DY.!P.~~ ......... ~k~pg..~..~p~Y~..~9..p~pD~..ND~h., .... Wih~..~p..~b~ ......... ~9~M~.,..Pp~..~.!..~pp~..ppp~9~..~y~pg..%p9..~%..~d... 1.9Y~9~~.~ .... Pp~..~.!..~~.,..~..~p~w~y., ..... :clipped a light pole and tree, hit an 8 foot sectiop came to rest on top of another tree. Driver of Unit DIAGRAM[] ONE WAY[] TWO WAY[] DIVIDED 0 I NDICAYE NORTH FACTORS AND CONDITIONS LISTED ARE THE INVESTIGATOR'S OPINION FACTORS/CONDITIONS CONTRIBUTING 2 3 UNIT 2 1. ANIMAL ON ROAD -- DOMESTIC 2, ANIMAL ON ROAD -- WILO 3.BACKED WITHOUT SAFETY 4.CHANGED LANE WHEN UNSAFE S.DEFECTIVE OR NO NEADLAMPS D.DEFECTIVE OR NO STOP LAMPS 7.DEFECTIVE OR NO TAIL LAMPS G.DEFECTIVE ORNOTURN SIGNAL LAMPS 9.DEFECTIYE OR NO TRAILER BRAKES 10. DEFECTIVE OR NO VEHICLE BRAKES 11. DEFECTIVE STEERING MECHANISM 12. OEPECTIVE OR SLICK TIREA 13. DEFECTIVE TRAILER HITCH 15. DISREGARD STOP &NO GO SIGNAL 18. OTHER FACTORS/CONDITIONS MAY OR MAY NOT HAVE CONTRIBUTED 19, DISTRACTION IN VEHICLE 20, DOIVED INATTENTION 21. DROVE WITHOUT HEASUGHTS 22, FAILED TO CONTROL SPEED 23, FAILED TO DRIVE IN SINGLE LANE 24. FAILED TO GIVE HAlF OF ROADWAY 25. FAILED TOTO HEED WARNING SIGN 26. FAILED TO PASS TO LEFT SJ~ELY 2T, FAILED TO PASS TO RIGHT WELY 2R, FAILED TOSIGNAL OR RAVE WRONG SIGNAL 29. FAILED TO STOP AT PROPER P~E 30. FAILED TO STOP FOR GOaL BUR 31. FAILED TO STOP FOIl TRAIN 32. FAILED TO YIELD DO~ -- EMERGENCY V~41CLE 33. FAILEO TO YIELD I~ -- ~ INTERSECTION O-NO CONTROL OR INOPERATIVE I 1-OFFICER OR FI.J~&MAN 2-STOP AND NO SIGNAL 3-STOP SIGN 4-FLADHING NED UGHT 37. FAILED TO TO YIELD ROW -- TURNING LE~'T 38. FAILED TO YIELD ROW -- TURN ON RED 39, FAILED TO YIELD ROW -- YIELD SIGN 40. FATIGUED OR ASLEEP 41. FAULTY EVADIVT ACTION 42. FIRE IN VEHICLE 43. FLEEING OR EVADING PQUCE 44. FOLLOWED TOO CLOSELY 45. HAO OEEH ORINION~ 46. HANOICJ~ ORI~R (EX~N IN I~RATIVE) 47, ILL (EIO~ IN NANRATWE) IMPAIRED VISIBILITY (E~ IN NARRATIVE) 40. II~OP~G ST~ FGOM ~ PORTION 51, OI~NED DO011 IMED TILM~ LANE 52, OVEORIED VERICLE OR LOAD TRAFFIC CONTROL 5-TURN MARKS lO-NC PADSING ZONE 7-AR GATES OR SIGNALS O-CEHTED STRIPE OR DIVIDED 56, PANNED WITHOUT UGHTO 57. PAUSED IN NO PASSI~ ZOHO 58. PASSED ON RIGHT SHOULDER 59. PEDESTRIAN FAILED TO R'ICLD ~ TO VEHICLE OR. SPEEDING -- UNEAFE (UNDER UNIT) 62. TAKING MEDICMION (EXPLAIN IN NARRATIVE) 63. TURNED EDPGO~LY -- CUT CORNER ON LEFT 64. TUIINED IMPRO~LY -- ~ I~HT TURNED IMPAD~LY -- N~ LA~E ED. TUONED WIJEH UNSAFE 67. UNDER INFUJ~ICE -- ALCOHOL ED, UNDER INFLUENCE -- ORHO ED, ~ SIDE -- ,~opROGOIJ OR IN INTERSECTION DISNERAGO STOP SIGN OR LIGHT INSNEDAIIO TUNN MANAS AT INTERSECTION OISRERAItD WAIINIHO SIGN AT CONSTRUCTION 34. FAILED TO YIELD ADW - PRIVME ORflfE 30, FASIra TO YIU ADW -- STOF SION 3~. FAILET~ TO YIELD ROW - TO PEDESTRIAN S.W. Burres, III #439 6~# 11I 'sa/an8 '~'$ / -,,.. 'IOOH~S H~IH "i'lS:l~hlO~) n TEXAS PEACE OFFICER'S ACCIDENT REPORT PLACE WHERE ACCIDENTcouNTY OCCURRED~t~ t 1~ IF ACCIOENT WAS OUTSIDE CiTY LIMITS, INOICATE DISTANCE FROM NEAREST TOWN ROAD ON WHICH ACCIDENT OCCURRED [ (~) {:-'~ R/OCR NUMBER INTERSECTING STREET OR RR X'iNG NUMBER NOT AT INTERSECTION BLOCK NUMBER ST.3 (Eft. 1/1/96) MAIL TO: ACCIDENT RECORDS, TEXAS "" MILES CITY OR TOWN NORTH S E W OF ~TMENT OF PUBLIC SAFETY, PO BOX 4087, AUSTIN TX TO773-0001 SHOW ONLY iF INSIOE CiTY LIMITS CITY OR TOWN STREE~q~ ROAD NAME~d' ROUTE NUMBER OR STREET CODE STREET OR ROAD NAME ROUTE ~MBER OR STREET CODE ~FT. ~ OF SNOW MILE~$T OR N~RE~T [NTERSECTIN~ NUM~EREO HIGHWAY. ~ MI. N S E W ~ NONE, SHOW N~RE~T INTERSECTING STRE~ OR R~ERENCE ~INT. CONSTR. F'TYES SPEED ZONE (~-NO LIMIT CONSTR. []YES SPEED ZONE Qi~NO LIMIT ACCIDENT k,~.~l~5~' J ~ 19 WEEK HOUR [] P.M. OR MIDNIGHT, SO STATE ,,,c. NO.97-O~ ~'.5 ?,~ DO NOT WRITE IN THIS SPACE LOC. CODE SEVERITY ~ FAT. AEC __ DR. REC. __ DPS NO. U,,T ,F ROOY STYLE = VA, ORBUS. NO. I - MOTOR VEHICLE VEH IDENT NO ~ / ~,~ <~ ?~,~Z~ '~ INDICATE SEATING CAPACI~ YEAR CO~R ~ MODEL I~9~ ~ ~ MODEL BODY LICENSE & MAKE -van ~A~ NUMBER DRIVER'S ~ / FIRST MIODLE ADDRESS (STREW, CI~, ~ATE, ~P) DRIVER'S ~ STATE NUMBER C~SS/~E MO ~ DAY' YBR PEACE OFFICER, EMS DRIVER. SPECIMEN TAKEN (ALCOHOL/DRUG ANALYSIS) I-~ 1-BREATH 2-BLOOD 3-OTHER 4-NONE 5-REFUSED ALCOHOL/DRUG ANALYSIS RESULT #/~ FIRE FIGHTER ON EMERGENCY? [] YES ~.0 LESSEE [] '~UCl~.~.l~...(..~g'L, ,,.,~,,,g ~. t0.,~" ~'~(~-.~J~-/~"'~'-' ~--------~/~...~*C/ /~ ~l ~ OWNER ~ NAME (ALWM$ SHOW LESSEE I~L~ED, O~ERWISE SHOW OWNER) ADDRESS (STREW, CI~, STME, Zl~ LIABILI~ ~YESi I , INSURANCE COMPANY NAME ~UCY NUMBER UNIT MOTOR VEHICLE ~ TRAIN [] PEDALCYCLIST [] "0. 2 TOWED r-] PEDESTRIAN [] OTHER [] VE. ,DENT NO'~H35F&b~87?G~ YEARMoDEL ~0 COLOR, _ MODEL~ ~/3~ BODY ~0/ ' & MAKE ~ ~3~AME ~ STYLE ~T FIRST MIDD~ ADORE$S (~RE~, CI~, STME, DRIVER'S LICENSE ~X 06~47~4 ~ DOB O?/Z~I?~ RACE ~ SEX F SPECIMEH TAKEN (ALCOHOL/DRUG ANALYSIS) l-BREATH 2-B~OD 3-OTHER 4-NOHE 5-REFUSED-- ALCOHOL/DRUG ANALYSIS RESULT OWNER ~ NAME (ALWAYS SHOW LESSEE IF LEASED, OTHERWISE SHOW OWNER) AOORES$ (3i~i, CI~, STATE, LIABILITY ~YES ~ ct 0~ ~c INSURANCE ~ NO ~ IF BOGY STYLE = VAN OR BUS, INDICATE SEATING CAPACITY LICENSE PLATE YEAR STATE NUMBER PHONE occuPA. ON PEACE OFFICER, EMS DRIVER, FIRE FIGHTER ON EMERGENCY? [] YES ~I NO INSURANCE COMPANY NAME 'A'3Aoo44 POUCY NUMBER VEHICLE DAMAGE RATING t Z FL- Z~ DAMAGE TO PROPERTY OTHER THAN VEHICLES OBJECT NAME AND ADDRESS (STREET, CITY, STATE, ZiP) OF OWNER FEET FROM CURB DAMAGE ESTIMATE LIGHT [~ CONDITION 1-DAYLIGHT 2-DAWN 3-DARK-NOT LIGHTED 4-DARK-LIGHTED 5-DUSK WEATHER ~ I-CLEAR/CLOUDY 6-SMOKE 2-RAINING 7oSLEETING 3-SNOWING 8-HIGH WINDS 4-FOG 9-OTH ER 5-BLOWING DUST SURFACE CONDITION 1-DRY 2-WET 3-MUDDY 4-SNOWY/ICY 5-OTHER TYPE ROAD SURFACE 1-BLACKTOP 2oCONCRETE 3-GRAVEL 4-SHELL 5-OIRT 6-OTHER DESCRIBE ROAD CONDITIONS (INVESTIGATOR'S OPINION) IN YOUR OPINION, DID THIS ACCIDENT RESULT IN AT LEAST $500.00 DAMAGE TO ANY ONE PERSON'S PROPERTY? [] YES [] NO CHARGES FILED NAME CITATION CHARGE NUMBER JT,ME.OT,F.EO ?.'asA M OF ACCIDENT ~'m ' TYPED o, P,,,TEO ,AME OF ,,VES,,GATO, SIGNATURE OF INVESTIGATOR TIME ARRIVED AT --,~.; -- .- '-" .... J %ij,~,.,i,?C4.i~.~gZ* $CENEOFACCiOENT~.~?i:~q:~7 ~,c/~ A MI 0 I o~TE HOUri I DATE RE~RT MADE ~ ~/~ IS RE~COMPL~E ~YES ~ NOr IDNO.~8 ,EPA.MEN~" I SOLICITATION (SOL) INDICATES PERSON'S DESIRE TO RECEIVE CONTACT FROM PERSONS SEEKING PROFESSIONAL EMPLOYMENT AS/FOR AN ATTORNEY, CHIROPRACTOR, PHYSICIAN, SURGEON. PRfVSTE iNVESTIGATOR, OR ANY OTHER PERSON REGISTERED OR UCEHSED 8Y A HEALTH CARE REGULATORY AGENCY. Y--O.K. TO SOLICIT N--NO SOUCITATION A - HOT API~JCASLF Y - YES N - NO P - PARTIALLY U - UNK UNIT NO. I I TOWED OUE VEHICLE DAMAGE I COMPLETE ALL DATA ON ALL OCCUPANTS' NAMES, mSITIONS, RESTRAINTS USED, ~C.; HOWLER, OCCUPANT'S J IT IS N~ ~SITION [ NECESSARY TO SHOW ADDRESSES UNLESS KIL.D OR INJURED. NAME (~ST NAME FIRST) ADDRESS (STREW. CI~, STATE, ZIP) USED J CODE FOR TYPE J AIRaA6 CODE HELMET USE CODE FOR AlCOHOL/DRUG ANALYSIS I (OOMP~ IP J RESTRAINT USED ; J INJURY SEVERITY J IN MOTOR VE,!_eLe NGT ,c.c..,..T ::NODE. YMEH, I UNK IF GEDLOYEO J S - WORN-UNK IF UAMAGED O - HON INCAR~CITATING J 3 - OTHER J E - SNOULOEH STRAI~ ONLY J C - PSSSIGLE INJURY / 4 - NONE JN - NONE J 4 - NOT WORN N - NOT INJURED 5 -REFUSEO J O - UNK IF WORN J VEHICLE UNIT NO. 2 (COMPLETE ONLY IF UINTNo., WAS A MOTOR VEHICLE) ToTOWEO OOEDAMAGE REMOVED TO .. t ~' J ~ id~, ~4~.~,~,J ~,~'a~t~¢' i)~'~ DAMAGE ~ COMPL~E ALL DATA ON ALL OCCUPANTS' NAMES, ~SITION8, RESTRAINTS USED, ~C.; HOW"ER, OCCUPANT'S fit IS NOT NECESSARY TO SNOW ADDRESSES UNLES~ KILLED OR I~URED. POSITION NAME (UST NAME FIRST) ADDRESS {STREW, CI~, STATE, ZIP) DR VER / SEE FRONT COMPLETE IF CASUALTIES NOT IN MOTOR VEHICLE PEDESTRIAN, PEDALCYCUST CASUALTY NAME LAST NAME FIRST) CASUALTY ADDRESS (STREET, CITY, STATE, ZiP) ETC. DISPOSITION OF KILLED AND INJURED TEM NUMBEDSI k TAKEN TO I BY TYPE J SOL J E~ECTEO I'E'WaJAIRRAG IHELNETI AGE J SEX IIN~JURYI ITIME ; F ;IMF/~UAL~FNI:EE; S E O'N ;~ OAT~END ANTS NOTIFIED I AT SCENE INC. DRIVER I COMPLETE THIS SECTION IF PERSON KILLED ITEM NUMBER DATE OF DEATH INVESTIGATOR'S NARRATIVE OPINION OF WHAT HAPPENED (ATTACH ADDITIONAL SHEETS IF NECESSARY) ..... . ..... ............ ..... ............. ...~. d.~ .... /.~ ~.... ~...(~ ..... ~ F....~.¢~.~.,....Z~.¢~ ~ ....... .... ~L[,.~...~.~....~.(~.~[ ....... I.Z.F.~...~...(~.~6~ ............ ..~.~.~S~ ~lZ.~m ~eS ............................................... ...................... :]i~. ~ e ~c~ ....................... .................... ~.~.Z~. ~'6~: ~'t~? .................................................. O,.~.M [] o.E WAV u.~,o wA~ ~O,V,DEO '.,CATE NORTH ///1/z) , U/1/v/////// I FACTORS AND CONDITIONS LISTED ARE THE INVESTIGATOR'S OPINION OTHER FACTOflS/CONOITIONS MAY FACTORS/CONDITIONS CONTRIBUTING OR MAY NOT HAVE CONTRIBUTED 1. ANIMAL ON ROAD -- DOMESTIC 2. ANIMAL ON ROAD -- WILD 3. RACKER WITHOUT SAFETY 4.CHANGED LANE WHEN UNSAFE 5.OEFECTIVE OR NO HEADLAMR$ 6.DEFECTIVE ORNOSTOP LAMPR 7.OEFEDTIVE OR NO TAIL LAMPS 8. DEFECTIVE OR NO TURN SICNAL LAMPS 9. DEFECTIVE OR NO TRAILER 8RAKES 10. DEFECTIVE OR NO VEHICLE BRAKES 11. DEFECTIVE STEERING MECHANISM 12. DEFECTIVE OR SLICK TIDES 13. OEFECYIYE TRAILER HITCH 14. DISABLED IN TRAFFIC LANE 15. DISRERARO STOP ANO GO SIGNAL lO, DISREGARD STOP SIGN OR UGNT 17. DISREGARD TURN MAGI~ AT INTERSECTION 18. DISREGARD WARHIN~ SIGN AT CONSTRUCTION 19. OI$TRACTIOO IN VEHICLE 20. DRIVER INATTENTION 21. OROVE WITHOUT HEAOUGHTS 22. FAILED TOCONTROL SPEED 23. FAILER TO DRIVE IN SINGLE LANE 24. FAILED TO GIVE HALF OF OOAOWAY 25. FAILED TOTO NEER WAGNIN6 SIGN 26. FAILED 10PASS TO LEFT SAFELY 27. FAILED TO PASS TO SIGHT SAS:ELY 2&FAILED TOSIGNAL OR 6AVE WORN6 SIGNAL 2~. FAILEO TO STOP AT PEOPRR PUCE 30. FAILED TO ..P FOR SCHOOL BUS 31. FAILED TO STOP FOR TSAJN 32. FAILED TOYIELD ROW-- EMERGENCY VEHICLE 33. FAILED TOYIELE ROW-- OPEN INTEHKECTIINI 34. FAIl. FO TO YIELD DOW -- PRIVATE DRIVE 35. FAILED TO YIELD ROW -- STOP SIGN 36. FAILED TO YIELD ROW -- TO PEDESTRIAN O-NO CONIROL OR INGPSRATIVE TRAFFIC CONTROL 5-TORN MAGKE lO-NO PASSING ZONE 1.-OFFICER OR FL~MAII 6-WAGNING SIGN Il-OTHER CONTROL 2-STOP AND OO SIGNAL 7-RR DATES OR SIGNALS 3-STOP SICN l-YIELD SIGN 4-FLAGINNO RED UGHT 9..CENTED STRIPE OR DIVIDER 37. FAILED TOTO YIELD ROW -- TURNING LEFT 3LFAILED TO YIELD ROW -- TURN ON RED 39, FAILED TO YIELD ROW -- YIELO SIGN 40. FA'rI~UEO OR ASLEEP 41. EAULTT EVASIVE ACTION 42. FIRE IN VEHICLE 43. FLEIrlII~G OR EVADING I~UCE 44. FOLLOWED TOO CLOSELY 45. HAD BEEN ORINKING #, HANOICN~ OOIVEH (EXPLAIN IN NARRATIVE) 47. ILL (EXPLAIN IN NARRATIVE) 48. IMPAIREG VISIGJUTY (EXPLAIN IN NARRATIVE) 49. IMPROPER STANT FROM PARKED I~SITION ER. I.OAO NOT SECURER 51. OPENER OO0~ INTO TRAFFIC LANE 52. OVERSIZE VEHICLE OR LOAD S3. OVERTAI(E AIdO PASS INSUFFICIBIT CLEARANCE 54. PAGKEH AND FAILED TO SST OO, AI~ 55. PANNED IN TRA.CFIC LANE SD. PAGDEO WITHOUT UGHTS 57. PASSED IN NO PASSING ZONE 58. PASSED ON EIGHT SHOULDER 59, P~DE..IAN FAILEO 'ro YIELD ROW TO VEHICLE 60. SPEEDING -- UHSAFE (UNOER LIMIT) 61. SPEEDING -- OVER OMIT 62. TASINO MEDICATION (EXPLAIN IN NARRATIVE) 63. TORHED IMPROPERLY -- CUT CORNER ON LEFT 64. TURNED IMPROPERLY -- WIOE RIGHT S5. TURNEO IMPROPERLY -- WNOIIG LANE 66. TURNER WHEN UNRA.CE 57. UNOER INFLUENCE -- ALCOHOL ER. UNDER INFLUENCE -- DRUG 69. WRONG SIDE -- AP~H OR ININTERSECTION TO. WRONG SIDE - MOT PASSING 71. WRONG WAY -- ONE WAY ROAG 72. OTHER FACTOR (WRITO IN ON ONE BELDW) TEXAS PEACE OFFICEr'S ACCIDENT REPORT PLACE WHERE IF ACCIDENT WAS OUTSIDE CITY LIMITS, INDICATE DISTANCE FROM NEAREST TOWN MAIL TO: ACCIDENT RECORDS, TEXAS D£ ~%4ENT OF PUBLIC SAFETY, PO BOX 4087, AUSTIN TX 78773-0001 SHOW ONLY IF INSIDE CITY LIMITS CITY OR TOWN ST-3 (Eft. 1/1/~,w MILES NORTH S E W OF ACC'DENTOCCURRED 2r , INTERSECTING STREET eLocx NUMBER STREE~r OR ROAO.~ME ~ - RDUTE~BER OR~TR~d~~ OR RR X'ING NUMBER CITY OR TOWN CONSTR. []YES SPEED ZONE []NO LIMIT~ CONSTR. I~YES SPEED ZONE r~NO LIMIT BLOCK NUMBER STREET OR ROAD NAME ROUTE NUMBER OR STREET CODE NOT AT INTERSECTION [] FT. [] [] [] [] OF []MI.N SEW SNOW MILEPOST OR NEAREST INTERSECTING NUMBERED HIGHWAY. IF NONE, SNOW NEAREST INTERSECTING STREET OR REFERENCE POINT. !DA, EDF O '-O L ACCIOENT LOC. NO~ -~L~~ DO NOT WRITE DPS NO. IN THIS SPACE CODE SEVERITY~ FAT. REC. [] A.M. IF EXACTLY NOON OR. REC. HOUR ~l)~r~) [~M. OR MIDNIGHT, SO STATE IF BODY STYLE = VAN OR BUS, INDICATE SEATING CAPACITY BODY LICENSE STYLE PLATE AGORESS (STREET, CITY, STATE, ZIPI DO6 RACE ~ MO DAY YEAR UNIT NO. 1 - MOTOR VEHICLE VEH IDENT NO YEAR COLOR MODEL MODEL & MAKE NAME DRIVER'S NAME DRIVER'S LAir ..... FIRST-- MIDDLE LICENSE YEAR STATE NUMBER PHONE NUMBER [YES []NO STATE NUMBER CLASS/TYPE SPECIMEN TAKEN (ALCOHOL/DRUG ANALYSIS) [---1 1-BREATH 2-BLOOD 3-OTHER 4-NONE 5-REFUSED LESSEE ~ OWNER E NAME (ALWAYS SHOW LESSEE IF LEASED, OTHERWISE SHOW OWNER) SEX __ ALCOHOL/DRUG ANALYSIS RESULT OCCUPATION PEACE OFFICER, EMS DRIVER, FIRE FIGHTER ON EMERGENCY? ADDRESS (STREET, CITY, STATE, ZIP) LIABILITY [~ YES INSURANCE [] NO INSURANCE COMPANY NAME P~UCY NUMBER VEHICLE DAMAGE RATING UNIT MOTOR VEHICLE]~ TRAIN ~ PEDALCYCLIST [] t t:FT]. NO. 2 TOWEO ~ PEOE~IAN a OTHER ~ VEH IOENT NO __ _ _ INDICATE SEATING CAPACITY YEAR ~)10 COLOR ~; MODEL ..... NAME _ STYLE NAME ,t~ .~.~ ~~ , NUMBER DRIVER'S ~ ' ~ ~ ' FIRST' MIOOLE~ AGORESS (STREW, CITY, STATE, ZIP) LICENSE DOB RACE SEX OCCUPATION STATE NUMBER C~SS/TYPE MO ~Y Y~R ~ SPECIMEN TAKEN (ALCOHOL/DRUG ANALYSIS) ~-~ )~ ijr~j,~ PEACE OFFICER, EMS DRIVER, i-BREATH 2-BLOOD 3-OTHER 4-NONE 5-REFUSED ~ ALCOHOL/DRUG ANALYSIS RESULT~ FIRE FIGHTER ON EMERGENCY? [] YES ~0 OWNER ~ t~L~ I , IF L HOW ~ , ) ~ - AGDR~SS (STREET, CIIY, ST~, ZiP) ' ' - -- INSURANcELIABILITY ~.~,i~S ,~~ '~m ,~I~...~ ~L'~. /"~;~9"~L:~I~-- F~~L"~ ~.,.~ -- ~ VEHICLE DAMAGE RATING ~ INSURANCE CO.,MPANY i~qldE POUCY NUMBER - DAMAGE TO PROPERTY OTHER THAN VEHICLES OBJECT NAME AND ADDRESS (~¥1~Ei, CITY, STATE, ZIP) OF OWNER FEET FROM CURB DAMAGE ESTIMATE LIGHT ~ CONDITION 1-DAYLIGHT 2-DAWN 3-DARK-NOT LIGHTED 4-OARK-LIGNTED 5-DUSK WEATHER ! 1-CLEAR/CLOUDY 6-SMOKE 2-RAINING 7-SLEETING 3-SNOWING B-HIGH WINDS 4-FOG 9oOTNER 5-BLOWING DUST SURFACE CONDITION 1-DRY 2-WET 3-MUDDY 4-SNOWY/ICY 5-OTHER TYPE ROAD SURFACE 1-BLACKTOP 3-GRAVEL 4-SHELL 5-DIRT · 6-OTHER DESCRIBE ROAD CONDITIONS (INVESTIGATOR'S OPINION) IN YOUR OPINION, DID THIS ACCIDENT RESULT IN AT LEAST $500.00 DAMAGE TO ANY ONE PERSON'S PROPERTY? CHARGES FILED [] YES [] NO ¥1~..~ CITATION NAME CHARGE NUMBER CITATION NAME CHARGE NUMBER SOLICITATION (SOL) INDICATES PERSON'S DESIRE TO RECEIVE CONTACT FROM PERSONS SEEKING PROFESSIONAL EMPLOYMENT AG/FOR AN ATTORNEY, CHIROPRACTOR, PHYSICIAN, SURGEON, PRIVATE INVESTIGATOR, OR ANY OTHER IERSON REGISTERED OR UCENSED DY A HEALTH CARE REGULATORY ~GEH CY. Y--OK. TO SOLICIT H--NO SOL C TAT ON EJEC A - NOT APPLICABLE Y - YES N - NO P - PARTIALLY U - UNI( CODE FOR TYPE AIRBAG COOE i HELMET USE RESTRAINT USED U - UNK IF OEPLOYEO A - SEATDELT & SHOULDER STRAP Y - DEPLOTEO 1 - WORN-DAMAGED B - SEATDELT & NO SHOULDER STRAP N - NO DEPLOYMENT 2 - WORN-NOT DAMAGED C - CHILD RESTRAINT - WORN-UNK IF DAMAGED E - SHOULDER STRAP ONLY - NOT WORN N - NONE -UNR IF WORN UNIT NO. 1 TOWED DUE TO DAMAGE DAMAGE RATN6 [] YES [] NO VEHICLE REMOVED TO BY CODE FOR INJURY SEVERITY K - KILLER A - INCAPRCITATING INJURY 6 * NON INCAPACITATING C * POSSIOLE INJURY N - NOT INJURED ALCOHOL/DRUG ANALYSIS (COMPLETE IF C~SUALTIES NOT IN MOTOR VEHICLE} 1 - BREATH 2 - BLOOD 3 - OTHER 4 - HONE 5 - REFUSED COMPLETE ALL DATA ON ALL OCCUPANTS' NAMES, POSITIONS, RESTRAINTS USED, ETC.; HOWEVER, OCCUPANT'SIT IS NOT NECESSARY TO SHOW ADORESSES UNLESS KILLED OR INJURED. POSITION NAME (LAST NAME FIRST) AODRESS (STREET, CITY, STATE, ZIP) DRIVER SEE FRONT UNIT NO. 2 (COMPLETE ONLY IF UNT TOWED DUE VEHICLE ~N~, 2 WAS A MOTOR VEHICLE) I TO DAMAGE I REMOVED TO DAMAGE COMPLETE ALL DATA ON ALL OCCUPANTS' NAMES, POSITIONS, RESTRAINTS USED, ETC.; HOWEVER, ,T ,s .UT .ECEB..Y TO S.OW ADONESSES U.LES..OR ,.JU.EO. DRIVER SEE FRONT NAME (lAST NAME FIRST) ADDRESS (STREET, CITY, STATE, ZIP) COMPLETE IF CASUALTIES NOT IN MOTOR VEHICLE PEDESTRIAN, PEDALCYCLIST CASUALTY NAME (LAST NAME FIRST) CASUALTY ADDRESS (STREET, CITY, STATE, ZiP) ETC. DISPOSITION OF KILLED AND INJURED ITEM NUMBERS TAKEN TO BY COMPLETE THIS SECTION IF PERSON KILLED SOLE,F, CTEJ II£STRklNT AIRDAG HELMET ROE SE][ INJURY USER, COOE TAKEN ICODE I IF AMBULANCE USED, SHOW ITEM NUMBER DATE OF DEATH TIME OF DEATH ITEM NUMBER INVESTIGATOR'S NARRATIVE OPINION OF WHAT HAPPENED (AITACH ADDITIONAL SHEETS IF NECESSARY) ,c INDICATE I i'7 -1 IUAGRAMN°RTH [] ONE II IWAY [] WAY [] Il ..OEO ! I ! i d J I I I I FACTORS AND CONDITIONS LISTED ARE THE INVESTIGATOR'S OPINION FACTORS/CONDITIONS CONTRIBUTING 1. ANIMAL ON ROAD -- OOMESTIC 2. ANIMAL ON ROAD -- WILD 3. BACKED WITHOUT S~STY 4. CHANGED LANE WHEN UNSAFE 5. DEFECTIVE OR NO HEAl)LAMPS ~. DEFECTIVE ON NO STOP LAMPS I.DEFECTIVE ORNOTAIL LAMPS S*OEFEOTIVE OR NO TURN SIGNAL LAMPS 9.DEFECTIVE OR NO TRAILER DDAKER 10. DEFECTIVE ON NO VEHICLE DP, AXES 11. SELECTIVE STEERING MECHANISM 12. DEFECTIVE ON SUCK TINES 13. SEFEOTI~E TRAILER HITCH 14. OlS~BLED IN TI~FIC L~E 1S, OlROGG/d~O ~ AND NO ~I~NAL 10. O~OERAND STOP SIGN ON UGHT OTHER FAOTORS/CONDITIONS MAY OR MAY NOT HAVE CONTRIBUTED O-RD CONTROL OR INOPERATIVE l-OFFICER ON FL~MAN 2-STOP AND 60 SIGNAL 3-STOP SIGN 4-FLAGN NG RED UGHT TRAFFIC CONTROL 5-TURN MARKS 6-WAGNIN6 SIGN 7-RR OGRES Off SIGNALE g-YIELD SIGN 9-CENTER RYINPE OR DIVID[III lO-NO PA~SING ZONE Il-OTHER CONTROL 3T. FAILED TO TO YIELD ROV/-- TURNING LEFT 3~. FAILED TO YIELD ROW -- TURN ON RED 39. FAILED TO YIELD ROW -- YIELD SIGN 4Q. F~T1GUED OR ASLEEP 41. FAGLTY L~RSIVE ACTION 42. Fill[ IN VEHICLE 43. FLF. F. IUG OR EVAOING P~UCE 44. FOLLOWEO TOO CLOSELY 56. PARKED WITHOUT LINNTS 57. PASSED IN NO PA~GING ZONE 58. pASSED ON RIGHT SHOULDER 59. PEDERYRIAN FA)LDO TO YIELD DOW TO VEHICLE 60. SPEEDINO -- UNSAFE (UNDER UMIT) 61, SPEERINO -- OVER UMIT 62. TAKING MEDICATION (EXPLAIN IN I~RATIVE) 63. TOUNEH IMPSO~LY -- CUT CORNEH ON I~ 64. TURNER [IIPSfJPERLY -- WIDE SI6HT 65, TURNED IIlNNO~DLY -- WNONG Udf AG. THANER WEN UNSAFE 67. UNOEfl INFLUENCE -- ALCOHOL ED. UNDER INFLDENCE -- ONUN H. MIONO SlOE -- A.q~IOACH OR IN INTERSEOTIOM TI. WN~ NMY ~ ONE WAY NOAD 72. OTHER FO (NOUTE IN ON UNE BELOW) TEXAS PEACE OFFICEI~S ACCIDEN~T REPORT PLACE WHERE ACCIDENT OCCURRED[} L cOU,TY ~ \ ~% INDICATE DISTANCE FROM NEAREST TOWN ROAD ON WHICH ACCIDENT OCCURRED INTERSECTING STREET OR RR X'ING NUMBER BLOCK NUMBER NOT AT INTERSECTION ~) O ST-3 (Ell. 1/1/ MILES MAIL TO: ACCIDENT RECOROS, TEXAS DEP~T~MENT OF PUBLIC SAFETY, PO BOX 4087, AUSTIN TX 7877:~0001 SHOW ONLY iF INSIDE CiTY LIMITS NORTH S E W OF CiTY OR TOWN ~,, ~ co,sT.. [] YES SPEED ~t~ · ZO,E ~:,o L,M,T STREET on ROAD qAME~ ROUTE NUMBER OR STREET CODE CONSTR.~ YES SPEED ZONE ~ NO LIMIT STREET OR ROAO ,AME ~OU~MBER OR STRE~ COOE SNOW MILE~ST OR N~AE~ INTERSECTING NUMBERED N~HWAY, ~ MI. N S E W ~F NONE, SH~ N~flEST iNTERSECTING ~flE~ OA REFERENCE ~1~. DATE OF ACCIDENT oq- 19q1~ OAT OF WEEK HOUR ~"~ [] A.M. IF EXACTLY NOON CS~.P.M. OD MIDNIGHT, SO STATE 00 NOT WRITE IN THIS SPACE LOC. COOE SEVERITY __ FAT. REC. DR. REC. ~ DPS NO. UNIT NO. I - MOTOR VEHICLE YEAR MODEL DRIVER'S NAME DRIVER'S LICENSE SPECIMEN TAKEN {ALCOHOL/DRUG ANALYSIS) [] 1-BREATH 2-BLOOD 3-OTHER 4-NONE 5-REFUSED ALCOHOL/DRUG ANALYSIS RESULT LESSEE [] OWNER ~ I?O~t~ ~r~_~fls~ ~.0. i~o~ T?'~ ~~\~L ¥,~ I NA'TIE IAI.WAYS SHOW LESSE~'IF LEASED, OTHERWISE SNOW OWNERI ADOI~'~S (STREET, Cl'l'~, STATE. ZIPI LIABILITY ~ YES INSURANCE ~NO 4s~. ~-~'~-~.~ P~ ~c)9'~r'~-4 IF BODY STYLE = VAN OR BUS. co~, & MAKE ~~0 MODEL BODY LICENSE NAME ~0~ STYLE ~'U ~ ,~TE ~ ~ ~ ~  FIRST MIDOLE ' '~ORE~$ (STREET, C~, ETAT~, ~P)~ I ~ STATE C~S/TY~ MO OAY ~AR P~CE OFFICER, EMS DRIVER, FIRE FIGHTER ON EMERGENCY? ~ YES INSURANCE COMPANY NAME POUCY NUMBER ~ TRAIN ~ PEDALCYCMST ~ UNITNo. 2 TOwEDMOTOR []VE"ICLEpEDESTRIAN [] OTHER = VEH 'DENT NO/b YEAR q ~ COU" ~W MODEL BODY MODEL & MAKE ~k~ ~l~h STYLE NAME o,,~..~ ~b(0.~~ N I~ ~; ~t~~ ~ NAME - MIOOLE kOOR~S {fRE~. CITY,' S~TE, ZIP)- DRIVER'S NUMBER C~S/TYPE SPECIMEN TAKEN {ALCOHOL/DRUG ANALYSIS} l-BREATH 2-B~0D 3-OTHER 4-NONE 5-REFUSED~ ALCOHOL/DRUG ANALYSIS RESULT LESSEE ~ NAME (A~YS SN~ LEVEE I~LEASEO. ~HERWISE SHOW ~NERI ADDRESS (STREW. Cl~, STATE, aP) LIABILI~ ~YES .,. ~ INSURANCE ~ NO ~ ~ ~o~L ~ ~(~'~'~ IF BODY STYLE = VAN OR BUS, INDICATE SEATING CAPACITY L'CE"SE PLATE T,.TA~iE NIJMIER PHONE NUMBER-- Jc~ - OCCUPATION Alq[ ~[ j~,h PEACE OFFICER, EMS DRIVER, FIRE FIGHTER ON EMERGENCY? ~YES ~NO VEHICLE DAMAGE RATINGL~_[~ ~ OAMAGE TO PROPERTY OTHER THAN VEHICLES OBJECT NAME AND ADORESS (STREET. CITY. STATE, ZiP) OF OWNEN FEET FROM CURB OAMJ~E ESTIIL~TE LIGHT ~ CONDITION 1-DAYLIGHT 2-DAWN 3-DARK-NOT LIGHTED 4-DARK-LIGHTEO 5-DUSK WEATHER 1-CLEAR/CLOUDY 2-RAINING 3-SNOWING 4-FOG 5-BLOWING DUST SURFACE COND T ON 6-SMOKE 1DORY 7-SLEETING 2-WET 8-HIGH WINOS 3-MUDDY 9oOTHER 4-SNOWY/ICY 5-OTHER TYPE ROAD SURFACE I-BLACKTOP 2-CONCRETE 3-GRAVEL 4-SHELL 5-DIRT 6oOTHER DESCRIBE ROAD CONDITIONS (INVESTIGATOR'S OPINION) ._) IN YOUR OPINION, DID THIS ACCIDENT RESULT IN AT LEAST $500.00 DAMAGE TO ANY ONE PERSON'S PROPERTY? [~LYES [] NO CHARGES FILED ,.~? TIME ARRIVED AT p~_~.~..~, b;~'~:~ ~M TIME NOTIFIED ~_~ 7 ¢ "3~ ~. HOW ~C~ a~ SCENE OF .CClOENT~' ~1 IT OF ACCIDENT - ~TE NObn 1 TYPED OR PRINTED NAME 0F I~R ~C~a~b. %- H~¢~ DATE RE~ MAOE~~-~ ~ IS RE~RT COMPL~E ~E, O NO SIGNATURE OF INVESTIGA'R ~~~ ~~ - 'DNO. ~ OEPARTMENT~[( ~'~ ' DIS'/AR"~,, SOLICITATION (SOL) INDICATES PERSON'S DESIRE TO RECEIVE CONTACT FROM PERSONS SEEKING PROFESSIONAL EMPLOYMENT AG! FOR AN ATTORNEY. CHIROPRACTOR, PHYSICIAN, SURGEON. PRIVATE INVESTIGATOR, DR ANY OTHER PERSON REGISTERED OR UCENSED DY A HEALTH CARE REGULATORY AGENCY. Y--OK. TO SOLICIT H--HO SOLiCiTATION NOT APPt. IC~ELE YES NO PARTIALLY UNK COOE FOR TYP~ RESTRAINT USEO SEATBELT & EHOULUER ~rRAP SEATGELT & NO SHOULDER $TRJ~P CHILD RESTRAINT SHOULDER STRAP ONLY NONE AIRBAD CODE Y -OEPLOYEO N - NO DEPLOYMENT - UNN IF OEPLOYEO 9 e - NON iNCAPADITAT[NG I It'CONOL/ORUG ANALYSIS HELMET USE CODE FOR (COMPLETE iF CASUALTIES NOT INJURY SEVERITY iN MOTOR VTmCLE) I - WORN-DAMAGER I( - KILLED 1 - BREATH  . WORN-NOT DAMADEO~ - iNCAPACITATING INJURY - aLODO · WORH-UNK IF DAMAGED - OTHER - NOT WORN C - POSSIBLE ~NJURY - NONE * UNK IF WORN N - HOT INJURED .REFUSEO llem t OCCUPANT'S No. POSITION i DRIVER TOWED OUE VEHICLE UNIT NO. ,~s---~'-. , TO DAMAGE REMOVEO T~. OAMAGE RATING COMPLETE ALL DATA ON ALL OCCUPANTS' NAMES, ~SITIONS, RESTRAINTS USED. ETC.: HOWLER, IT IS NOT NECESSARY TO SHOW AOORESSES UNLESS KILLED OR INJURED. NAME (~ST NAME RRST) ADDRESS (STREW, CI~, STATE, ZIP) SEE FRONT OL """ .,T"~""' AIPSAD .E". "E S' 'NJU~ UNIT NO. 2 (COMPETE ONLY IF UNIT TOWED DUE ~O,~MO,l~R YEHICLE) TO[] OAMAGEyEs , DAMAGE _ ~;~e"O RATING REMOVED T~. T'~ ~-I v ~'~ COMPLETE ALL OATA ON ALL OCCUPANTS' NAMES, POSITIONS, RESTRAINTS USED, ETC.; HOWEVER, OCCUPANT'S IT IS NOT NECESSARY TO SHOW ADDRESSES UNLESS KILLED OR INJURED. POSITION I NAME (lAST NAME FIRST) ADDRESS (STREET, CITY, STATE, ZIP) DRIVER I SEE FRONT" I COMPLETE IF CASUALTIES NOT IN MOTOR VEHICLE PEDESTRIAN, PEDALCYCLIST CASUALTY NAME (LAST NAME FIRST) CASUALTY ADORESS (STREET, CITY, STATE, ZiP) ETC. DISPOSITION OF KILLEO AND INJURED TIME ' F ~lM:;~q ;ICv~ ~ S EU'N :~ A~EN D"TS ITEM NUMBERS TAKEN TO I BY NOTIF ED AT SCENE INC. DRIVER SOL SP~II~EN RESULT HELMET AOE SEX INJURY COMPLETE THIS SECTION IF PERSON KILLED ITEM NUMBER DATE OF DEATH TIME OF DEATH I ITEM NUMBER DATE OF DEATH TIME OF DEATH I ITEM HUMBER DATE OF DEATH TIME OF DEATH INVESTIGATOR'S NARRATIVE OPINION OF WHAT HAPPENED (ATTACH ADDITIONAL SHEETS IF NECESSARY) [ DIAGRAM [] ONE WAY [] TWO WAY [] DIVIDED ~[~%t~ (OU~,~,~ ..~ FACTORS AND CONDITIONS LISTED ARE THE INVESTIGATOR'S OPINION FACTORS/CONDITIONS CONTRIBUTING I UNIT2 I __ .' I _ I. ANIMAL ON HGAO -- DOMESTIC 2.ANIMAL ON ROAD -- WILD ZO- 3.BACKED WITHOUT SAFETY 21. 4,CHANGED L,IUdE WHEN UNSAFE 22, $.DEFECTIVE ORNOHGADLAMPS 23. D.OEFECTIVE ORNOSTOP LAMPS 24. 7.OEFECTIVE OR NO TAIL LAMPS 25. S.OEFECTIVE OR NO TURN SIGNAL LAMPS ER. 9.OEFECTIVE OR NO TRAILED OR'RES 27. 10. OEFECTIYE OR NO VEHICLE DRAKES ER, I1. OEFECTIVE STEERING MECHANISM 20, 12. DEFECTWE OD SUCH TINES 30. 13, OEFECTIVE TRAILER NI1CN 31. 14. OISADLEO IN TGA*cFIC I.J~E 32. IS. SISREG~AO STOP ANO GQ SIGNAL 33. OTHER FACTORS/CONDITIONS MAY OR MAY NOT HAVE CONTRIBUTED OIGTDACTIOM IN VEHICLE OAIVER INATTENTION FAILER ~ TO HEEO WANNING SIGN F~LER TO STOP FUN SC~L NOS O-NO CONTDOL OD INOPERATIVE TRAFFIC CONTROL O-TURN MAAKS 18-N0 PASSING ZONE I-OFFICER OR FLAGMAN S-WARNINO SIGN 11-OTHER CONTROL 2-STOP AND GQ SIGNAL 7-AR GATES OD SIGNALS 3-STOP SIGN S-YIELO SIGN 4.FL~EH NG GED UGHT 9-CENTER STRIP~ ON DIYIOEH 37. FAILED TO TO YIELD ROW -- TURNING LEFT 31. FAILED TO YIELD ROW -- TURN ON REO 36. FAILED TO YIELD ROW -- YIELD SIGN 40. FATIGUED OR AGLEEP 41. FAULTY EVAGIVE ACTION 42. ROE IN VEHICLE 43. FLEEING OR EVADING PQUCE 44. FOLLOWEO TOO CLOSELY 45. HGQ BEEN OBIN~NG 4G. HANOICAP~O OGIVES (Lr~ iN NADDATr~I 47. ILL IEXPLBIH IN NARRATIVE) 48. IMPAJDER VISIBILITY (L~N IN NANDATIVE) 40. IMPROPER START FROM pARKED POSITION 54. LOAD NOT SECUDZO SL O~dIEH OOON INTO TI~FIC lANE ~2. OV~lGIZE VEHICLE SSI WAG S3. OVTNTAXE ANO IA,TI INDOFTICIENT CLEANANCE S4. pAJINEH AJdO FBILEH TO SST BRAKES SS. PAAI~ iN TRAFFIC LANE 56. PARKEO W1THOUT UONTS $7. PASSED IN NO PASSING ZONE 58. PASSED ON RIGHT SHOULDER 72. ~THEII F~ (WNITE IN Old UNO BELOW} TEXAS PEACE OFFICER*'S ACCIDENT REPORT STo3 (Eff.1/11~., MAIL TO: ACCIDENT RECORDS, TEXAS DE "-~ENT OF PUBLIC SAFETY, PO BOX 4087, AUSTIN TX 78773-0001 ACCIDENT OCCURRED cou. TY c,-- OR,OWN - --' IF ACCIDENT WAS OUTSIDE CITY LIMITS, [] [] [] [] I IHOW ONLY IF INSIOE CI~ LIMITS DO NOT WRITE DPS NO. INDICATE DISTANCE FROM NEAREST TOWN MILES NORTH S E W OF IN THIS SPACE CI~ OR TOWN ACCIDENT OCCURRED 8~CK NUMBER STaR'OR ROAD NXMEJ ROUTE NUMBER OR STREET CODE INTERSECTING STREET CONSTR. YES SPEED OR RR X'ING NUMBER ZONE ~ NO LIMIT ~ S~ERI~ ~ B~CK NUMBER STREET OR ROAD NAME ~TE NUMBER OR STREET CODE NOT AT INTERSECTION ~0 ~FT. ~ ~ ~ OF g~U~J [ ~ - MI. N S E W SHOW MILE~ST OR N~RE~ I~ERSECTIN6 NUMBERED HIG~AY. FAT. AEC. IF NONE, SHOWNEAREST INT~ECTING STRE~ OR REFERENCE ~INT. 19~ DAYOF I ,~ ~A.M. IF EXA~LY NOON WEEK ~ _ "OUR ~~". OR MIDNIGHT, SO STATE NO. 1 - MOTOR VEHICLE VEH IDENT NO . INDICATE SEATING CAPACI~ COLOR h ~[~.~ MODEL BODY NUMBER __ FIRS~ ~ __ MIDOLE ADDRESS (STR~ CI~, STAT~IP) - I e ..... · ~ ~ ~ATE NUMBER~ ~ C~SS/TYPE SPECIMEN TAKEN2.BLOoo(A~OHOL/DRUG3.0THER 4-NoNEANALYSIS)5-REFUSED~ ALCOHOL/DRUG ANALYSIS RESULT ~~ PEACE OFFICER, EMS DRIVER, 1-BREATH FIRE FIGHTER ON EMERGENCY? ~ YES MA~ (ALWAYS SHOW LESSEE IF LEASED, OTHERWISE S~ ~NER) ADDRESS IS~, CITY, ~ATE, ZiP) " ' " YES ' INSURANCE ~ - ' I~SURANCE COMFY NXME - ~LICY NUMBER UNIT MOTOR VEHICLE"~''~ TRAIN [] PEDALCYCLIST [] PEDESTRIAN [] OTHER [] COLOR ~ MAKE ~0~ ~. ~.C. NO. 2 TOWED ~ MODEL NAME FIRST DRIVER'S STATE NUMBER ~ PHONE MIDDLE ' - ADD.SS i~. CITY, STATE,~IP) ' - ' ........ ~ 0o, ~ I l .5S~ ,~c~ ,, ~ ~x .~ occ.~.o. ~l~ C~SS/~PE MO DAY YEAR - ~ VEH IDENT NO ..... INDICATE SEATING CAPACITY MODEL BODY LICENSE ~y~R TS.m~TE .... STYLE . . [] YES ~NO SPECIMEN TAKEN (ALCOHOL/DRUG ANALYSIS) [~ PEACE OFFICER, EMS DRIVER, 1-BREATH 2-BLOOD 3-OTHER 4-NONE 5-REFUSEO ALCOHOL/DRUG ANALYSIS RESULT ~N,~)L~--,,, FIRE FIGHTER ON EMERGENCY? OWNER '~ NAME (ALWAYS SHOVrLESSEE IF LEASED,'"'T)TNERWIST~ ~'HO~"B~VNER)ADDRESS (STREET, CITY, STATE, ZIP) LIABILITY .,~YES - I .r ~ ..SU.A.CE [] .o ~tF_ ~ ~N. f~t~ 4'flL~l,~-..,,'~z,~ ~og'~qt,:,qdO'Ib - - ~ INSURANCE COMPANY NAM[ - - -- POUCY NUMBER DAMAGE TO PROPERTY OTHER THAN VEHICLES 08JEll NAME AND AODRESS (STREET, CITY. STATE. ZIP) OF OWNER FEET FROM CURB DAMAGE ESTIMATE LIGHT ~-~ CONDITION 1-DAYLIGHT 2-DAWN 3-DARK-NOT LIGHTED 4-DARK-LIGHTED 5-DUSK WEATHER 1-CLEAR/CLOUDY 6-SMOKE 2-RAINING 7-SLEETING 3-SNOWING 8-HIGH WINDS 4-FOG 9-OTHER 5-BLOWING DUST SURFACE CONDITION 1-DRY 2-WET 3-MUDDY 4-SNOWY/ICY 5-OTHER TYPE ROAD SURFACE 1-BLACKTOP 2-CONCRETE 3-GRAVEL 4-SHELL 5-DIRT 6-OTHER DESCRIBE ROAD CONDITIONS (INVESTIGATOR'S OPINION) J IN YOUR OPINION, DID THIS ACCIDENT RESULT IN AT LEAST $500.00 DAMAGE TO ANY ONE PERSON'S PROPERTY? ~k.YES [] NO CHARGES FILED CITATION CITATION NAME CHARGE NUMBER SOLICITATION (SOL) INDICATES PERSON'S OESIRE TO RECEIVE CONTACT FROM PERSONS SEEKING PROFESSIONAL EMPLOYMENT AS/FOR AN AI'rDONEY, CHIROPRACTOR, PHYSICIAN, SURGEON, PRIVATE INVESTIGATOR, OR ANY OTHER PENDON REGISTERED UR LICENSED BY A HEALTH CARE REGULATORY AGENCY. Y--O.K, TO SOLICIT N--NO SOLICITATION F. JEC~. CODE FOR TYPE AIRBAG CODE HELMET USE RESTRAINT USED NOT APPtlCASLE Y - DEPLOYED I - WORN-RAMAGED YES B-SEATBELT & NO SHOULDER STRAP oNO DEPI.OVMENT 2- WORN-HOT OAMAGED NO C * CHILD RESTRAINT UNK IF DEPLOYED - WQRN-UNK IF DAMAGED PARTIALLY E - SHOULDER STRAP ONLY - NOT WORN UNK N - NONE . UNK IF WORN UNITNO. 1 TOWEDOUE VEHCLE ~.~-..,,~*l A... ~.. ~"A-. i ,~ .~--,x~l~ I ~ [ TO DAMAGE REMOVED TO - ~ ~ ~ ~l~ ~)~ ~l~ DAMAGE ~ ' ~ ~ COMPLETE ALL DATA ON ALL OCCUPANTS' NAMES, ~SITIONS, RESTRAINTS USED, ETC.; HOWLER, OCCUPANT'S ~ IT IS NOT NECESSARY TO SHOW ADORESSES UNLESS KILLED OR INJURED. ~SITION~ NAME (~ST NAME FIRST) ADDRESS (STREW, CITY, STATE, ZIP) J DRIVER SEE FRONT UNIT NO. 2 (COMPLETE ONLY IF UNIT TOWED DUE t VEHICLE .TN ~.o ,~, | NO. 2 WAS k MOTOR VEHICLE) TO DAMAGE REMOVED TO ~.~"~. ~- ~1~;~1~ ,AT,,oDA"AGE \ [] YES ¢.,..oI o', --; I COMPLETE ALL DATA ON ALL OCCUPANTS' NAMES, POSITIONS, RESTRAINTS USED, ETC.; HOWEVER, OCCUPANT'S IT IS NOT NECESSARY TO SHOW ADDRESSES UNLESS KILLEO OR INJURED. POSITION NAME (LAST NAME FIRST) DR VER SEE FRONT ADDRESS (STREET, CITY, STATE, ZIP) COMPLETE IF CASUALTIES NOT IN MOTOR VEHICLE PEDESTRIAN, PEDALCYCUST CASUALTY NAME (LAST NAME FIRST) CASUALTY ADORESS (STREET, CITY, STATE, ZIP) ETC. DISPOSITION OF KILLED AND INJURED TEM NUMBERS TAKEN TO I BY CODE FOR (COMPt. ETE IF CASUALTIES NOT INJURY SEVERITY IN MOTOR VEHICLE) K - KILLED 1 - 6REDTN A-INCAPACITATING IMJUflY BLOOD B*NON INCAPACITATING -OTHER C - POSSIBLE INJURYNONE N - ROT INJURED REFUSED J usED/ I / / GooE, / TYPE SOL EJECTE~ arSTflJUNT AIRRAG HELMET AGE SEX INJURY .ME A..,VED N D AT SCENE INC. DRIVER COMPLETE THIS SECTION IF PERSON KILLED I--TONEWAY ~-~IWOWAY r'~DIVIOEO .,~ FACTORS AND CONDITIONS LISTED ARE THE INVESTIGATOR'S OPINION FACTORS/CONDITIONS CONTRIBUTING ...T, , %%'-1' 1. ANIMAL ON ROAD -- DOMESTIC 2. ANIMAL ON ROAD -- WILD 3. RACKEO WITHOUT SAFETY 4. CHANGED LANE WHEN UNSATE 5. DEFECTIVE OR NO HEDDLAMPS E* DEFECTIVE OR NO S1T}P LAMPS 7. DEFECTIVE OR NO TAIL LAMPS 8. DEFECTIVE OR NO TURN SIGNAL LAMPS 9. DEFECTIVE OR NO TRAILER BRAKES 10. DEFECTIVE OR NO VEHICLE BRAKES 11. DEFECTIVE STEERING MECHANISM 12. DEFECTWE OR SUCK TIRES 13. OEFECTIYE TRAILER HITCH 14. DIS~LED IN TRAFFIC ULME 1S. DISREGARD STOP AND O0 SIGNAL lA* DISREGARD STOP SION OR LIGHT lT. DISR£RAOE TORN MARKS AT INTERSECTION 16. DISREGARD WARNII~ SIGN AT CONSTRUCTION OTHER FACTORS/CONDITIONS MAY OR MAY NOT HAVE CONTRIBUTED 2 19. DISTRACTION IN VEHICLE 20. DRIVER INATTENTION 21. DROVE WITHOUT HEADLIGHTS 22. FAILED TO CONTROL SPEED 23. FAILED TODRIVE IN SINGLE LANE 24. FAILEO TO GIVE HALF OF ROADWAY 25. FAILED TO TO HEED WARMING SIGN 26. FAILED TO PASS TO LEFT SAFELY 27. FAILED TO PASS TO RIGHT SAFELY 28. FAILED TO SIGNAL OR GAVE WRONG SIGNAL 29. FAILED TOSTOP AT PROPER PLACE DO. FAILED TO STOP FOR SCHOOL 80$ 31. FAILED TO s'roP FOR TRAIN 32. FAILED TOYIELD ROW-- EMERGENCY VEHICLE 33. FAILED TOYIELD ROW-- OPeN INTEGGECTION 34. EAIL~ TOYIELD ROW-- PRIVATE DRIVE 35. FAIIIm TO YIELD ROW - STOP GION 36. FAILEO TO YIELD ROW -- TO PEDEHTSIAN O-NO CONTROL OR INOPENATIVE 1-OFFICER OR FLAGMAN 2-STOP AND GO SIGNAL 3-STOP SIGN 4-FLASHING RED U6HT TRAFFIC CONTROL 37. FAILED TO TO YIELD ROW -- TURNING LEFT 38. FAILED TO YIELD ROW -- TURN ON RED 39. FAILED TO YIELD ROW -- YIELD SIGN 40. FATIGUED OR ASLEEP 41. FAULTY EVASIVE ACTION 42. FIRE IN VEHICLE 43, FLEEING OR EVADING POUCE 44. FOLLOWED TOO CLOSELY 45. HAD BEEN DRINIONG ~.HANOICAPP'ED DRIVER (EXPLAIN IN NARRATIVE) 47, ILL (EXPI.AIN IN MANPJ~TIVE) 48. IMPAIRED VISISIUTY (EXPLMN IN NARRATIVE) 49. IMPROPER START FROM PARKED POSITION 50. LOAD NOT SECURED 51. O~>"cNED DOOR INTO TSI~FTC LANE 82. OVERSIZE VEHICLE OR LDAG 5.1. OOECTA~ ~dD P~G INSUFFICIENT CLEARANCE 54. PAIII~D AGO FAILED TO SET GRAKE$ 5~. PARKER IN TRAFFIC lANE 56. PARKED W1TGOUT LIGHTS 57. PASSED IN NO PASSING ZONE ED. PASSED ON RIGHT SHOULDER 56. PEDESTRIAN FAILED TO YIELD ROW TO VEHICLE GO. SPEEDING -- UNSAFE {UNDER LIMIT) 61. SPEEDIN~ -- OVER OMIT 62. TAKING MEHICATIC~ (E~PL.AIN IN NARRATIVE) 63. TURNED IMPROPERLY -- CUT CORNER ON LEFT 64. TURNED IMPROPEHLY -- WIDE RIGHT 55. TURNED IMI~ROPERLY - WRONG UUJE &L TURNER WNEN UNSAFE 67. UNDER INFLUENCE -- ALCOHOL ED. UNDER INFLUENCE -- DRUG OG. W~ SIDE -- AI~ROACH Off IN INTERSECTION 7D. WNOId~ SIDE -- NOT PASSIRO 71. WlI~JG WA~ -- ONE WAY ROAN 72. OTHEH FACTOR (~NITE IN ON ONE G~ · T t