MISSOURI
UNIFORM
1 - GENERAL
CRASH
CRASH
REPORT
PAGE I OF 5
z:7Am:mlf(=hQ
INFORMA110N
SPACE USED FOR BARCODE
LEFTTHESCENE
DRIVERNO
H Y" € No I I I
n'e",'_t$$7 44';4if;Bs
2
I
CLEARED
CRASH
W =aw= €q=r== NO. INJuREDNO KILLED
I 58yes € N- CLASSIFICATION (gl
0
i
0
WEEr_(-JIW) W
;c_____5$i4_g; u$i-'jA
mtQ___:e
2055
04-15-2017
-'- 205g)
04-15-2017
I
04-15-2017
._.7;-i.
:; poqowpy NON-COLLISION
="-'q al
[]
[]
' fflXlo"
Overiummg
Fite I
[]
COLLISIONINVOLVING
0 Animal
[] RailwayVehicle
[i Pedalcycle
[] Animal DrawnVeh/Animal RiddenTtans.
Fell/Jumped
F'o"'MV
c,:,-6Road"ay
Explosion
a Loss/Shca'go/E91,"p
0 Fixed
Ob4ect
W Motor
Vehicle
inTJansport
%
,,i,%re:
€
oRo"adway
a
Jackkn.lfeaOthe,"""""'o"
[]
Other
Ol:Ject
0
Parked
MotorVehicle
_.;,,
€
Non-Collision
[] Pedestrian
[] Working MotorVehicle
0417-129
J
iVjp,(gl§):
2055
.
OYes
@ No
I DIRECTIONALANALYSISFOR IMPACTWITH MOTORVEHICLE
[]
10
Frontto Front
Frontto Reai
[]
[]
Angle
Sideswipe(SameDir.)
[3
0ther
(Explain)
[] Rear
toRem % Sideswipe
(Opp
Dir) 0 Unknown
[] Falling
r
Shming
Cargo
(Explain)
(sa' "' "o"o" bYM')
l[] Rear
toSide
gp'i'aWaq
e_eJb%'F__o'l_lF_ffrTh"foy_
_a__:,f@o576Bu'iJg_ETp_'a'_ilRi3ffl
'9_e:@lji)3g:gyHlR;i:[EJ'm_(;[email protected];$")3H4
1 Doesthis ttash involveany o+the Tollomng7
7___7g_zii,;g7lj_Ql
2. Examineeachvehicleto dgkermineif it is a commercialvehicle based uponthe Tollowinq'
1b A pttrsonttanspottedTormedicalattention OR
i a Ap8i5(y1
j8i8ii7
iplured,
ot;l
@ No _ NOcomme,jai vehicle
Tieldsneed completion
2a AtruCk
I CatgO
Van
wrth
GVWR
/ GCVWR
Oi more
than
€ Qo _ NO(;0111
mercialv8§j0iO{j8i(15
need completion
1c Avehicle
towed
duetodisabling
damage.
@ Yes _ Goto ,umbe, 2
2b
Amotor
vehicle
withseating
for9 ormore
including
dnvet,
OR
2c A vehiclewith a hazardousmaterialsplacatd
z
EVIDENTIARY
PHOTOS
TAKEN
N) Yes [] No
RECONSTRUCTION
10.000 Ibs.OR
BY WHOM
AVAILABLEFROM
A.MALAGON
Yes _ CompleteSection 7G lo,
appropriatevehicle
0 InvestigatingAgency
NEOHSO POLICE DEPARTMENT
110
BY WHOM
AVAILABLEFROM
'
0 InvestigatingAgency
[1 Yes % No
2 - LOCATION
V44
'%u".1
NEWTON
'aoa"
CST
qa3=_ep'lipjI4
25
SPRING
HILL
$m2_'@
:4F;@
NEOSHO
N
@
-f'J-'-'
DR
_Bp3gLyAtU;§i$-@- z Unknown
[] State € County % Municipal € Private Piopetty
-estei-a:r;stpT@K'TJi"i"
NNE
$N5aE-6_j:Cij
-
€
[]
'3i[gT§i
BeTore
ROAD ALIGNMENT
one_wiiy
W Two-Way,Not Divided
0
Two-Way,Not Dvided, ContinuousCentet Tum Lane 0
-INTERSECTIONTYPE
[1
0
N of CST
NA
[]
Two-Way,Divided:LlnprotectedMedian
0
Two-Way,Divided,PosAiveMedian Barrier 0
[]
0
ST
"
-5-4p3-offl-_
E
NA
ROAD PROFILE
Straight % Curve
Unknown(Explain)
[]
[]
Level %
Uphill 0
Downhill 0
Hillciest 0
Dip
Unknown(Expliin)
EN6osT*
NA
4-wayIntersection 0
T-Intersection
a
0ther
unknown
W MCCORD
Jaei..
25
TR AFFICWAY
0
[]
€
Aftei
Miles
i
'
§'T
_
E NA
Feet
[] Other
--
ffi
Y-Intetsection []
Roundabout m
5-way/ More
[]
Other (Explain)
Unknown(Explain)
WEATHER
ROAD SURF ACE
[]
Concrete
0
Brick
0
Did/Sand
0
%
Asphalt
[]
Gravel
[1
Multi-SurTace []
%
0
Cobblestone
Llnknown(Explain)
CONDITION
Clear []
Cloudy []
Rain []
Snow 0
Sleet / Hail
0
Fnsezing(Temp) []
Fog I Mist
0
Severe Crosswind []
0ther (Explain)
Unknown(Explain)
a;j€ a6miji'Dt3jl=
[] DayiiQhF"aTk-Li9hted
€
€ Da+k-unknOWn
Lighting € Other (Explain) 0
DaTk-Llnl:ghied
UnknOWn (EXplain)
'.SiD?MA-G.!j.m!:J!40'!.ERT)Y.'9!i!E!-TtUS!6!!!iFl!_CuE8-:
% None
LIST OWNER'SNAME& ADDRESS,DESCRIPTIONOF PROPERTY,AND DAMAGE. € MODOT
4 - WITNESS
Th None Idenbhed
NO
ADDRESS
I
N NA
€ Law EnforcementOfficer
NAME (LaSt, FITSI, Ml) & ADDRESS
SEX
DATE OF BIRTH
(Street, City, State, Zip)
0
a
€
[]
ROAD
[] Other EmergencyServices Personnel
z
Other Trafficway Worker
a
,
STRUCK
BY VEH #
INJ
TRANSPORT
SAFETY
DEVICES
LOCATION
0
€
lk
Ilnn
CIRCLIMSTANCES
FailedTo Yield
Distracted/ Inatteniive
COPYAGENCY
[1
[1
Alcohol
Diugs
FILE,
Other Pedestnan
PHONE NUMBER
[]
[]
0n Roadway
On Sidewalk
OTHERACTIONS % NA I None
WithSignal 10 NotAtCrosswalk 0 GettingOn I Off Vehicle
[] Standing/ Lyin / Sitting In Trafficway
AN00:41gsinaSlignal
[]a MUnamrkae,dkeC;oCs,s0waff
lk 0 Pushing/ WorkingOn Vehicle
0 BehindI In Front of Paiked / StoppedVeh
Unknovin 10 Unknown
DISTRIBUTION
@ MODOTWorker
In Dtiveway
Access
Off Roadway
€
0
On Median
/ Crossing
Island
Unknown
-
W NA
PROBABLECONTRIBUTING
[]
0
PHONE NUMBER
(St+eet, City, State, Zip)
I
CROSSIIIIG
€ Hun,c,pa,ly
a Addihonal witnesses In Nairative
NAME
s - PEDESTRIAN
0 County
€
[]
[] None
Vision Obstiucted (Explain)
PhysiaalImpairment(Explain)
SCHOOL
[]
0
[]
[]
Working In Ttafficway
PlayingIn Trafficway
Walking/ RunningIn Ttafficway
th Traffic [] AgainstTtaffic
oisreqc'rtonxqvrexrivecoob(s)
€
0
Other (Explain)
Unknown(Explain)
ORIGINAL-MISSOURISTATEHIGHWAYPATROL.TRAFFICRECORDSDMSION-P.O
0
[]
unknown
0
Othet (Explain) []
@ NA
BOX568-JEFFERSONCITY
Going
To /
NA
From School
GetUng On I Off School Bus
[]
Both Ot The Above
[3
Llnknown
ALCOHOL
€
111
[
INFO
Yes
MO65102
(Explain)
USE
a
No
€ unknown
SHP2Q
01112
REPORT
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PAGE 2 0F 5
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NORTH
WeSt MCCOrdStreet
A
n
-N
a
-"vehicle's
-
-rin
were
-
moved
.
the impact point
prior to my arrival.
from
s pg
1V2
Hill Drive
:
c
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t
--
---1
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.,
REPORT # OjH7-129
7-DRIVERS,
VEHICLES,
OWNERS,
PA €3E 3 0F 5
& OCCuPANTS
l'f!:).A
PHONE NuMBER
5@E8iiL.
o9">=,,
0%EQ5L
K_!iN4tYn@0N_
_%kr;%;4:3r?33,Sfff,_;,%LTo
N ST,06 _ NEOSHo, Mo 64850
a'l -
DRIVER LICENSE
I ID NUMBER
ST ATE
RO78104011
o,-57Ig:'a;:ji'j7_
SEX
09-21-1977
M
SEAT
LOC
FL
pBojQloe<-i.3TJg;1,
aYeS
[]
0
NO
Not Required
LIC
0
mATUS
%
€ NA 0
I MO
TRANSPORT
INJ
5
8Xmu-87
EJECTION
1
LIC
Expiied
DisqualCDL
Unknown
[]
Valid
[]
Susp / Rev / Denied
[]
Canceled/ 0th Invalid []
(')niiialnr
03
F
('.liiss
NA []
n
Interm/ Grad
051
ffl'A"a#?#M"POUNTRY
Unlicensed
Sign
Hillcrest
ParkedVeh
0 unknown (Explain)
0
0
0
POLICYNUMBER
PHONENO. (Optiona0
(417)
451-1504
-
MovingVeh
StoppedVeh
Glare
MODEL
COLOR
Buick
CENTURY
t7ffi_2
"2-' lllllllllli'l'l
G 4
W S
,[email protected]_;PT;-,i;4F3,o3
PMr_;roe,llye2qsol7
nm tIm%
l jIj5+__a,
H
Ja'-aa'
[] NA
2 ______1314_)
7
E
5
TOT AL NO OF OCC
1
1
2
J
4
Y
1
1
8
2
7 . 8
7
_:g5)-;g;
18 - undercarriage
22 - Cargo
19 -
23 - unknown
ndshield
VEH TYPE
MAR i
% st6a=
ii_eWEEERG)q:_S'§ENE aeweeaiieie:eisxttJk;4
7_iff(a0{o,'ii(!q-iig(j.qii4;d2%7i%:}_...
_a.p4;_ffl_ti4o-a4ne5+
€lj"l'Yj:44-.j
Other(Explain)
Unknown
(Explain)
phoraexuvst=ti
MAKE
2000
[]
[]
APVO536100
%g_j;j$:J4p*._..,lt7Jl..!':i4,F_p,
YEAR
M 'N"
&!&.
IS)prmi+
0
Trses/Biush
[]
Building
[]
Embankment 0
,jJ47-lm/ThRJ%ln
W'l
. r.!14
M )m d u'4.miim a;,;6';;,Ql!FpiA
TYPE5 ,;;,';,;:____7:
VISION
B NotObstructed [1
OBSTRUCTED @ Windshield
0
[] NA
@ LoadonVeh
0
mAG: MX[e,e
2
N
.
1_E
20-Burned 24-Other
6';q'-'-la-4---"
10,4
19
-' -""aaa--"'a
'-"-""
;gV-E_QtG$-E';2$gQj@s;/ip30ilk2 -lei6_ QQi;;H7i@p%4
a)l _ Trnhiotl
I III:+
tl-in'iliiiiil
§EE5:;E',:,WID,,,,Q8
:=::==(-:;':=o:=;'
O::"q : EE,E,,,::,pH,,,yM,,h
E_:=:_:====_L::==_=:=:_==
::I(.IffiQ=-==:i:fi='==-S::Ji=H:.(:::"':ffli":'fflW:'-i:Tt:.
[]To/FromSchool
i0unknown
2(ANERlElEln?aRX5_5Raa_G5ffl[-lffOIMJEfi:A':
EMERGENCYVEHICLEINVOLVEMENTE NA
0 Police
[] Ambulance)
0 Firii
0 0ther (Mustcheck"A" / "B") 7C. VEHICLE
ACTION
ISEQ-uENCE
SEQU41'JC:l',)aEt'[OEU(5Efg
[]
[]
OF EVENTS CODES
A EmetgencyVehicleon EmetgencyRun
B. Stationary th EmergencyEquip Activated
0
3
%
'
I
:
I
None
[] FailedTt) Dim HeadlightS
0 FailedTo Use Lights
[] FollowingToo Close
[] Wrong Side (Not Passing)
IJ VWongSide (One-Way)
[] PhysicalImpairment(Explain)
[] ImproperStart From Park
7p4;g:o3y--_
g None 0 Unknown
__0__Unk__nownElectnc
0 Green/YellowlRed a Flashing Red
=zexwo_mi
Yes
COd_eS L_iSted_in N__arrat__ive__(See__Cod__esinSec-t=n
No
Workeis
Ptesent
[]
Yes
gl No
7F
-
[]
-
Ottier
Controls
Unknown
----------
8)
_
-
_
_
_
-
-
Ili
"
_
_
_
l.:
ALCOHOLUSE
€ Yes
% Unk
[] NO
€ NA
aa-€
0
%
[]
IJ
0
[]
ImpropeT TOWing / Pushing
ImproperlyStoppedOii Roadway
ImproperLane Usage/ Change
Overconected
Imptopet RidingI ClingingTo Veh. Extenor
FailedTo Sscure LOadI ImPTOPeT
Loading
Animal(s)In Roadway
[] FlashingYellow
a Ramp Meter
[]
[]
[]
0
/ Ob8ttUCli0n In ROadWap
Distracted/ Inattentive(DesignateType)
Unknown(Explain)
0thet (Explain)
ObleCt
DATE OF BIRTH
SEX SEAT
LOC
TRANSPORT
'
l"
Ht4r@@ytBp7@
;lNOPEaTaE4'RllSEilFIG's.-o
a Other (Explain)
INJ
ENA
DISTRACTED/INATTENTIVECODE(S)
(See Codes in Section 8)
€ Stop Sign
€ NOPassmgZone
[] Tum Restticted
0 0fficei / Flagman € Signal On School Bus
[] Waming Sign / Device [] Railway Crossing Sign / Device € School Zone 0 Yield Sign 0 0ther (Explain)
OCCUPANTS - NAME (Last, First, Ml)
-ADDRESS (Street, City, State, Zip)
_
;Bi7Q20t'ff5Ci_6o5pq
MElt&<[aff(8MW--E
%0.1 i
4i
:
i
i
I
i
I
-'76}PROMME:QC-NiCRIBDTIN(3',(QIRQtlMS2ANOESt': €
[]' VehlCle DeTel:TS (EXpl;l:n)
€ ViSiOnObStTuCled
[]
spiied - ExceededLimit
[:] Dtiver Fatigue/ Asleep
[1 Too Fast For Conditioiis
0 ImproperSignal
0 ViolatioriSignal/ Sign
[J ImproperBacking
13 FailedTo Yield
lj
Improper Ium
0 Alcohol
[] ImpropetPa8Slng
[] Drugs
0 ImpropetlyParked
0
AdditiOnal
[3 unknown
EJECTION
AIR
BAG
0 Yes (Explain)
€ Unknown
SAFETY
DEVICES
W No
[] NA
PHONE NUMBER
7G. COMMERCIALMOTORVEHICLE E NA I RequiredOnvehicle :{ "yes" was answeredto questions in parts1 and 2 in CMV involvementcriteiia and vehicle meets OneoTihe three ciiteiia in park2
MOTORCARRIERIDENTIFICATION(Leasee,etc ) - NAME& ADDRESS(Street,Ctty,8tate, Zip)
0 SAO
PHONENUMBER 0 soo.
/
[]
NON-COMMERCIAL []
COMMERCIAL
IntetstateCamer
InttaslateCatriet
0
0
Not In Comrnerce- GovernmentVehicle
Notln Commeice- RentalVehicle
[]
Not In Commerce- Other Vehicle
CARGO @ EnclosedBox
€ Flatbed a ConcreteMixer
€ Garbage/ReTuse
a PoleTrailet
TYPEBooY
0 Cargo
Tank [:l Dump [] Auto
Transpoder0 Grain
/ Chip
/ Giavel [] LO(I
PLACARD
HAZAIIDOUS
MATERIALS
[]
€
DISPLAYED
Yes [1] No
Unknown
4-DIGIT
NO
CLASS
HM CARGO
aYesCINo
[] Unknown
PRESENT
HM CARGO RELEASED
€
Yes
€
0
Llnknown
No
MC / MX / ICC NO
@ VehicleTOWintl
@ Interrryodal []
A"o" V"'
HAZARDOUS
M ATERIAL
USDOT NO
NA(No
€
Othet
ChassisBody)coo'a"""ca'go
0 unknown-N AME
a
REPORT # 0417129
7-DRIVERS.
VEHICLES,
OWNERS,
PAGE 4 0F 5
& OCCuPANTS
Ni:i$)'77,)4t313__t';lQ%AJ%(l_'_(a(
5gjt,4,'p@-(_pqQt(e3iE,',,%;;Sta-t<iz_N'2 ' EBER[E'7R-OBERTBRIAN-------'-i-4-15-i-N-SHADYLANEDR-NEOSHO,MO64850
DRIVER LICENSE
I ID NUMBER
ST ATE
YO78234003
oibr_i6:ni"0p
SEX
SEAT
LOC
M
FL
08-01-1957
map4eiH(tg4g-_tq5
[_I
[gYes
€
No
-YEAR
I MO
INJ
TRANSPORT
EJECTION
5
1
2
Valid
[l
Susp / Rev / Denied
€
Canceled/ 0th Invalid 0
thXfSs-a:
;E)AG!IFJ4t!
ijz
051
03
;aFf4-l:rpAfm-6f26fiB.E--EEjSXFEm-C:01NSaMi'C-E"""
Not Required
7p5ybycJp7q,-Q.'n)tfng-}(=i
LIC
E
'ATUS 0
€ NA €
H
oBSTRucTEo@
0 NA
@
PHONE
€ U'!aj";iI%gai'§J@6'-5_,mi7rffl.itW;4ii
Motor
ric3+_iss}';_QJT34
yiv-ffi
=-'2= G . T
I%"rK7-h4 YEAR
;INI:rlAUlMF94GJTh;1
2 I 3 I 4 I 51 6 I 7
l-
I'
l--
E
1:11:llll'l'll
19 -
MovingVeh
StoppedVeh
Glate
COLOR
C. 1
9
Unknown
0
€
(Explam)
0ther (Explain)
unknown
(EXmain)
§'B4§ij
jl8 4
[J NA
(g
VEH TYPE
BLK i
T
5
2 . 1
2
;-V_%J__U-'r_5o-,
0
6
2
5
SAD
TOT AL NO OF OCC
I
1
j$9Vg%9_j4E:7
OYes W NO
8
... i
-g(j,67
n - Cargo
ndshield
23 - unknown
;io - Bumed
2' - Towad "'
ll41kl"
[]
€
0
i@___et-ibgatt)sssHe-
is - Undercaniage
8
3
Sign
Hillttest
ParkedVeh
No
[1
PHONENUMBER
SIERRA
'VEH(G[Ei[:lKfA:A?UE(MaiM51i:lar;ag6d:a7e-a;4a_;;;[-4q-(i,6J51o7Q-aTh;,-
al2
-
$evex'r
0 Yes €
[X[ NA
MC Only
unlicensed
E SAD
Corp.
3S[Ja9a3-1- i-M-O-i 2018
'- '- --' - '-
332-3226
mmtrav-gsii
POLICYNuMBER
24654351
NO (Optional)
..(800)
0
0
Trees / Btush 0
Building
€
Embankment []
MODEL
General
€ NA
I<010bstructed 0
ndshield
a
LoadonVeh
[]
VISION
7151,p
aMnqip
TYPE.-..=-.,=..._IJ CDL Class
€ NA 0 IntermlGrad
taN
MAKE
2002
-=
Explred
DisqualCDL
Unknown
PHONE NUMBER
:_jl - Other
(Explain)
VEHKCEE
Bp,t8§C"A(itjm4_@,-Ep_!9iaity;V4-l_%i:
_O-X5!I_lCm_p;8-d;i
§'::,::EE'E,:,WID,,,,4
ffi=::==(-:;':=S=,=,;'
Or='="-q
: EE'EaE".','pH..,yM...h
B_:=:_:=-==L::==_::_=='=:_:
::I(=Jffi.$f"='
:iif"==:;.,.Wjy,t=H;-.';;;a':ffli'i'ffig=I:'-i:'t'.=:i
LI TOI FromSchool
i 0
0
[]
0 Additional Codes Listed in Nanative (See Codes in Section 8)
l'Jv7ff(:+T-e-J
'z unknown
-l
...i
i
01 3 4i
Vehide DeTects(Expliun)
Spee(l- ExceededLunit
roo Fast For Conditions
ViolationSignalI Sign
Failed'ro Yield
Alcohol
Drugs
[]
0
[]
0
lJ
0
[]
7LJ!V___opx_,U=;ffl.
.'tM-rUcaaaNffl:am
Worke+s
Ptesent
0 Yes E No
Other
€ Unknown
Conttols.
OCCUPANTS
7F.
-----
--
ADDRESS
[]
[]
[]
[]
Il
0
[]
i
Green/Yellow/Red
[]
0
Stop Sign
ImpropeiTowing/ Pushing
ImproperlyStoppedOn Roadway
ImproperLaneusage / Change
0vetconected
ImproperRiding/ ClingingTo Veh Extetior
FailedTo Secure Load/ ImproperLoading
Animal(s)In Roadway
0
[]
0
0
Flashing
No Passing
Sign / Device
[]
[]
Zone
Railway
€
Flashing
(>ossing
[]
Yellow
Turn Restricted
Sign / Device
[]
€
€
Ramp Meter
School
0
Zone
Other
€
Officer I Flagman
DATE OF BIRTH
MM-DD-YYYY
CARGO [3
Inirastate
EnclosedBox
Catrier
[]
DISTRACTEDr ixovi'exnvb
PLACARD
DISPLAYED
No
4-DIGIT
Unk
CODE(S)
% NA
(See Codes in Section 8)
"
SEX SEAT
LOC
Signal On School
Yield Sign
INJ
olt)IDF!EFbTJ!%5gMle(ill!l(?"'rj'F.
0 Yes (Explain) % No
..
0 Unknown
[] NA
(Explain)
0
TRANSPORT
0ther
Bus
(Explam)
EJECI:I, II
SAFETY
DEVICES
PHONE MJMBER
I
Notln Commetce- GovernmentVehicle
Not In Commerce
0
0 SAO
-=-=
0
PHONENUMBER
Not In Commerce- OtherVehicle
ConcteteMixei
NO.
CLASS
MC / MX / ICC NO.
€ SA9.
uSDOT NO
- Ren(al Vehicle
0
Garbage/ReTuse
0
PoleT(aileT
TYPEBoDY
€ cargo
Tank a Dump a Auto
Ttansporter
@ Grain
/ Ch:p
i Gravel@ LO9
HAZARDOLIS@ Ye,. z
MATERIALS a unknOWn
0 NA
I Required
0nvehicleiT"Yes"wasansweted
to questions
in paM1 and2 in CMVinvolvement
cnteriaandvehiclemeetsoneofthethieecriteriain part2
0
[]
Flatbed
NO
I I I
I
I
I
I
I
I
MOTORCARRIERIDENTIFICATION
(Leasee,etc ) - NAME& ADDRESS(Street,Crty,State,Zip)
IntersiateCatnet
€
M
i@zr;il@$$pgyHg;p+antrr4
Red
- NAME (Last, First, Ml)
-(Stteet, City, State, Zip)
7G.COMMERCIAL
MOTOR
VEIIICLE % NA
€
[]
Yes
0bled / Obstructionin Roadway
Distracted/ Inattentive(DesignateType)
unknown (Explain)
0ther (Explain)
0 Unknown
[]
0
[]
0
0
0
0
0
0
I
COMMERCIAL /
NON-COMMERCIAL
USE
€
'aa
Failed To Dim Headlights
FailedTo Use Lights
FtillowingToo Close
Wiong Side (Not Passing)
Wrong Side (One-Way)
PhysicalImpairment(Explain)
ImproperStad From Park
% None
€
Waming
J;ii"';es:i(:'c-;H:-?(s7-.
i
,
,
(gNone
Vision Obstructed
Dtiver Fatigue/ Asleep
ImpropetSignal
ImproperBacking
ImproperTum
ImproperPassmg
ImproperlyParked
Electric
[] Yes 3No __[l__Unk__now_n
ALCOHOL
JEIlMQoA#(A)
i
I
I
i
,'7D:,PROBdMECQ%7RlJl':j-l%(:i,-,Cl80UMSJANC#Ba'
[]
[]
[4
[3
0
0
0
.-
A EmergencyVehicleon EmergencyRun
B SletionaryWuh EmergencyEquip Activated
-7C VEHICLEACTIONI SEQuENCEOF EVENTSCODES
st;o'gE;ce-
Unknown
a-xzeisetinwieamsreeraaremeslgx
fiYVEHICLEINVOLVEMENT
[0 NA
[] Police
[] Ambulance
[] Fire
[3 0ther (Mus)ckieck"A" / "B") -4
HM CARGO
[3
[3
Yes
a
Unknown
PRESENT
No
HM CARGO
[1
Yes
[]
[]
unknown
RELEASED
No
0
VehicleTowing
Another
Veh
[]
Intermodal
0
Ccoantsasillnser
NA(No
0
0ther
socaWgy7
a Unknown
l .
-
REPORT
# 0417-129
a-coDEs
PAGE
'4%
SEAT LOCATION
XX - Not Known
/'
B - Pedalcycle
M - Mojorcycle
FL SL TL
CP - Coinmercial Passenget
OE - Occupant - Enclosed Load Atea
OU - Occupant - unenclosed Load Area
RC - Rail Ctew
SV - Other (Explain in Narrative)
NA - Not Applicable
EJECTION
TRANSPORTED
(For Medical
Treatment)
INJuRY
i
FDais'aabling
2'
3 EvidentNot Disabling
4 Probable Not Apparent
5 None Appatent
U unknown
N NA
AIR BAG
1
2.
3
4.
U.
S No
2 EMS
3 0ther
U. Unknown
N NA
31.NNoOn.
eoe/
pNloAyed 9.Combination
Deployed
2
NA
No
Partially
Totally
Unknown
4.
5
6.
7.
8.
Removed
10 Deployment
Deployed - Front
Unknown
Deployed - Side
u Ar Bag Presence
Deployed - Curkain
Unknown
Deployed - Other
(Knee, Ait Belt, elt. )
3.
4.
5
7
8
F'
FJ'l fQq
m wii
ri
5 0F
-i
_.._
5
_Z.
Ct.l!m;i leii
(! I !4J!
lia I mI-0
None
NotUsed
i."
"lffa!12!i%c:ng
Shoulder Belt Only
Lap BeR Only
Shoulder and Lap Belt
DOTCompliant
MC Helmet
No Helmet
12 Child Restramt - Rear Facing
13 0ther Helmet
14 RsTledive Clothing
15 0ther
U Use Unknown
N. Not Applicable
a
VEHICLE
ACTION
ISEQuENCE
OF
EVENTS
(ltems
with
double-aste+isk
["]requiie
additional
coding)
GOove"reaSki:':ag""
;oi :aac'k'iFng'o"
Pa'kad2190
AR'a'bnoO"ff"Roadway
229a'
sRa:uat'nae':do"TooR'
ouand"'way
34MRlla:h:inTguR,nig0htnTRuemd
1123
SPtao,pkepded
InTtaffic2221.
RoaVne,Ouff,nRloRaodwalloVye-,
LeTt330,
cCoo'l'llisslioonn
IlnnvV.
PBelcdyecslettliPaendalcycl6
39ClnolBlislc:oynclelnLvanBeicycle/Pedalcycle
0Rabjnecot,SRetOland:otyionoBlh
"
2'
- Right
5
Making
LeTt Turn
14
Changing
Lanes
23
Fire / Explosion
32
67MsakkldindglngU-lTSurlln,lng
1165
cAv,Oosidsinl,gedlan24
Immetsion
25 Jackknife
Collision
Inv Railway Veh
33Collision
InvAnimal
(')
34
Collision
37 Collllsllonlnv
Othe, Objed(Expla'in)
38. Othet Non-i.ollision
44
45
40
46
47
Collision
Inv Ammal Drawn Vehicle /
Th,OWn,FalVlng Ob,ed
Struck By Falling. Shflng
.
Catgo,
Cross Separator
Animal
Ridden
Foy
Transpofahon
Inv MV in Ttansport
41. Collision
Inv Working
MV
gsSSlioaw,inlngT/,Satfiolpcping
:78Ccrioossss
CReOantder
OT
Road
2267
CEqa:glpomLBonstsF/aSllhu::
3356.
CcoOllllilss:o0n,llnn:
PFa;ekdedOMb,Vedc,
4423,
FDeolwnllJuhmillpReudnFa,waomyMV
ANIMAL
CODES FOR VEHICLE
60 Deet
FIXED OBJECT
20
21
22
23
24
25
CODES
FOR VEHICLE
ACTION
OF EVENTS
Extetnal
I INATTENTIVE
62
I SEQtlENCE
T+ee/Stump(Standing)
Embankment / Driveway / G round / Rock Bluff
Guardrail Face
Utility Pole
Fence
Stteet Light Suppor)
DISTRM,TED
'l
ACTION I SEQuENCE
61. FarmAnimal
DOg
63
U u"k"o"'
0the+Animal
OF EVENTS
26. Culvert
27 Highway Ttaffic Sign Post / Support
;_s Bndge Pier / Abutment / Suppott
29 Cutb
30. MailBox
3'l Concrete Traffic Banier
32. Building
33. Ttaffic Signal Support
34 Impact Attenuator I Crash Cushion
35 Flre Hydrant
36 0ther(Explain)
37 Bndgs Parapet End
5
Communication
Oevice - Hand-held
9
Eating I ttinking
3 3. Computei
6 CommunicationDevice-HandsFree
10Reading
Navigation
VEHICLE
1
2
BridgeRail
Guatdrail End
0ther Tiaffic Banier
Overhead Sign Support
Ditch
0thei Post / Pole I Support
44
45
46.
47.
u
Wall
Cable Ba+rier
Bridge Overhead Sttuctute
Overhead Lme / Cable
Unknown
CODES
Dist+action
23 sPtaes,seeOnlgAerus,lolvldeOEqu.lpmelT.7
4
38.
39.
40
4j
42
43
Device
8
Communication
Commurucation
Device - Texting / E-mailing
Devioe - Web Browsing
14
12
Tobacco use
Gtooming
Equipment
t Electioiiic
Games
I etc
14.At5ustingVehicleContiols
15.
Other (Explain)
TYPE CODES
Motor Veliicle In Transport
Pa+kedMotorVehicle
OTHER VEHICLE
3. Working Motor Vehicle
4. Pedalcycle
5 Animal Drawn Vehicle / Animal Ridden
ll. Unknown
3 Snowmobile
4.Forklift
5
FOTTransport
Purposes
CODES
1 Ridinq Mower I Garden Tractor
2GollCarF
9.5 NARRATOVEVtSTAmME.NTS';[lf
additionalroom is
-l
On 04-16-2017
at approximately
a non injury traffic crash report.
Animal Dtawn Vehicle I Animal Ridden For Transportation
6 Low Speed Vehicle
70ther(Explain)
necessary,use Section11 - NarrativeI StatementsContinuation)
2055
hour,
Officers
responded
to the intersection
of Spring
Hill Drive
and West
McCord
Street to take
Upon my arrival I spoke with the driver of vehicle two who I identified by his Missouri drivers license as Robert Eberle. I asked Mr.
Eberle if he needed medical assistance
but he said he was okay. Mr. Eberle said he was traveling
north on Spring Hill Drive when a
vehicle traveling South failed to matntain hts lane and side swtped tum. Mr. Eberle sard the dnver did not stop but he did manage to get
his vehicle tag number of PM9F3W
Missouri.
Mr. Eberle sard the vehtcle looked like an older Buick car and was driven by a white male
subject. The tag number Mr. Eberle wrote down was PM9F3W
which comes back to a 2000 Buick Century. The owner of the Buick
Century is a Joel Elliott who resides at 321 Hamilton
apartments
406. Mr. Eberle said there was damage to the vehicle that hit him ori
the driver side. Mr. Eberle vehicle insurance
ts through Safeco Insurance.
Policy number Z4654351.
A good contact number for the
vehicle insurance
is 1800-332-3226
I went to 321 Hamilton Apartment
406 to make contact with the owner of the vehicle. I was able to locate the vehicle which matched the
description
that driver two gave me. The vehicle was parked on the parking lot with damage to the driver front side. There was some
black paint transfer from vehicle two located on the front corner panel. I was informed that Mr. Elliott apartment
number was 406. I went
to the fourth floor and made contact with Mr. Joel Elliot who I identified
by his Missouri drivers license. Mr. Elliott originally
denied being
involved in a traffic crash.
Once I explained
the physical evidence
I had from his vehicle and the statement
from the other driver he
said he did hit the vehicle on Spring Street and leff the traffic crash scene because he was scared. Mr. Elliott said the reason why he hit
the vehicle was becacise he made a "sharp turn." Mr. Elliott said he did not need medical assistance.
Mr. Elliott vehicle insurance
is
through Farm Bureaci Town & Country Insurance.
Policy Number is APVO5361 00.
I took photographs
Nothing
further
of the damage
to both vehicles
and they have
been attached
to this report.
at this time.
I
10.
REPORTING
AND REVIEWING
OFFICER
INFORMATION
nQ?;_i<_i_li<d7BIBlW3:_g%ra6_%2_
OFF ALFONSO MALAGON
_.
,
.'._
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-
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l_EV%3EW3NG;,O,F=ElGER§lljAl,;,
4Aw
9
p-:
i5-
-'41
y<o-p:Q_ ci4
"""'-l-""'
__
10- '
REVIEWING
OFFICER
2 NAME
-
-
'
a
'