TRAFFIC CRASH REPORT LOCAl REPOfIT NUMBER' CRASH SeVERITY HIT/SKIp

~ ,.FA.TAl ~ I· SoLVED, ~ ILOC~I>FOOMATION 16 MPD 0651 3 2· INJURY 2 2 UNSOlVED........ ' •.•••.".,.............. 16MPD0651 J. PD~

o PHOTOS TAKEN, I 0 ~~A~UNOER 10 PRIVATE (IREPORTING AGENCY NCIC'I REpORTING fl<:.ENCY NAME'

I NUMBER OF II U"TlN ERROR

DOH -2 DOH ·1P REPORTABLE PROPERTY []] U,,~ ~98.AuM~ o OH-3 O<mER Dou.AA AMouNT 03801 Millersburg Police Department 99 - UM<NOWN

COUNTY' DOry' OTY. V'UAGE. TOWNSHIP' CRASH DATE' TIME OF CRASH DAY Of WEEK

Holmes • VIUAGE' Millersburgo TOWNSHIP­ 04/29/2016 1723 Fri

DeGREESlMiMJTESiSECONDS I DeCIMAL DEGREES

LATITUDE LONGITUDE • LATITUDE LOI'Kl/TUOE

40:32:59.00 81 :55:05.80 i ROADWAY DIVISION DIVIDED LAf'.E DIRECTION OF TRAVEL NUMBER OF THRU lANEs ROAD TvPES on MiLEPClST

0 DIVIDED DN - NOOTIiaOUND E . EA$TBOUM) AL - Amv CR-O.cu HE· HEIGHTS MP - MlEPOST PL - PlACE ST - STREET WA-WAY

• Uf'.OlVlOED S - Soun-mouf\O W ,WESTBOUM) 2 AV· A""NUE CT· CouRT HW - HlCI-fW....v PK- PAAI<WAY RD - ROAD TE - TERRACE

BL - Bout...EvAAD DR - DRIVE LA -lA>E PI- PIKE sa - SouAAE TL - TRAIL

LOCATION ROUTE NUMBER Loc PREFIX LOCATION ROAD NAME C§:!] LOCAnON ROUTE TYPESo locATION IR ­ INTERSTATE ROUTE (THe. TURNPII(E)

ROOTE ~ N,S, ST ROAD

US - US RooTE CR - NUMBERED Couwv Rool. TYPE E,W Washington TYPE

SR - STATE ROUTE TR - NU.lotOE'RED TOWNS!" RouTE·

o.STANCE FROM REFERENCE Io.R FROM REF I REFERENCE REFERENCE ROUTE NUMBER IREF PRERX REFERENCE NAME (ROAD, MILEPOST. HOUSE.) REFERENCE OMLES ONS • OROUTE ~ N,S, 1ST IROADB~~DS E:W TYPE E,W Clay TYPE

REFERENCE POINT USED CRASH LOCATION OF FIRST HARMFUL EVENT

1 ·INTERSECTION LOCATION 01 - NoT AN INTERSECTION 06 - FIVE-POINT. OR MORE 11 - RAlLWAV GRADE CROSSlf'Kl

OJ 1 - ON ROADWAY 5 - o..GooE OJ 2 -MILE POST [QIJ 02 - FOUR. WAY INTERSECTION 07 - ON RAMp 12 ­ SHARED·USE PATHS OR TRAJlS

0 INTERSECTION 2 - ON SHOULDE

RELATED 6 - OJrsIDE TRAfFICWAY01 03 - T ·INTERSECTION 08 - OFF RAMp 99 - UNKNOWN 3 - IN MEDIAN 9 - UNKNO'NN3 -HOUSE NUMBER 04 - Y ·INTERSECTION 09 - CROSSOVER 4 - ON ROADSIDE

05 - T RAFFle ORClE! ROUNDABOtJT 10 - ~IVEWAYIAu...Ev ACCESS

ROAD CoNTOUR ROAD Cof'.VmONS

[i]' -STRAIGHT LEVEL 4 - CURVE GAAoe PRIMARY SECONDARY 01 - o.y 05 - SAM), MUD. DRT, OiL GRAVEL 09 - RuT.I-IoLEs. BUMPS. Ut-.EVEN PAVEMENT'

2 - STRAJGHT GRADE 9- UNKNC>\o'w'N [QIJ 0 02 -WET 06 - WATER (STAr-DING. MOVING) 10· OThER

3 - CuRVE leVEL 03 - SNOW 07 - SLUSH 99 - UNKNOWN

04 - lee 08 - DeBRIS· ·S~... COOOl'lONC>f,O.'1'

MANf'oER Of CRASH CoWSl()NAMPACT WEATl-IER

~ 1 - NOT CoU.ISlON BETWEEN 2 - REAR·END 5 - BACKJt«J 8 - SIDESWIPE. OPPOSITE

~ 1-CUAA 4 - RAIN 7 - SeVERE CROSSWlf'DS8 Two MOTOR VEHIClES 3 - HEAD-ON 6 - ANGLE DRECTION 2 - CLOUDY 5 • Sun, HAL 8 - &0WIf'Kl SAM),S<JjL, DRT, SNOW

IN TRANSPORT 4 - RE.A~Ho.REAR 7 - SIDESWIPE., SAME DiRECTION 9 - UM<NO'vVN 3 - FOG,SMOG. SMOKE 6 - SNOw 9 - OniERlU~NOWN

ROAD SURFACE. LIGHT OJt..iOOIONS ScHOOL. Bus RELATED

~ 1 - CoNCRETE 4 - SLAG ,GRAVEL, OJ PRIMARY DSeCO~AR 1 - DA'.1.JGHl 5 - DARK. ROADWAY NOT UGHTED 9 - UNKNO'NN 0 ScHOOl. o YES. ScHOOl. Bus

2 - BLACKTOP, STONE 2 - DA'NN 6 - DARK. UNKNO'NN ROADWAY LIQiTlf'Kl ZONE DiRECTl.Y ImOLVED

BiTUMINOUS, AsPtw.T 5 - o.RT 3 - DuSK 7· GLARE' RELATED o YES, ScHOOl. Bus

3 - BRicK/&OCK 6 - <mER 4 - DARK· UGHTED ROADWAY 8· <mER ·SEOONlo'JI¥COI'O'\lCf'/O....¥ ItORECTl.Y ImOlVED

O"-"A' o WORKERS PRESENT T VPE OF WORK ZONE LOCATION OF CRAsH IN WORK ZOto.E

ZoNE 0 LAw E1'FORCEMENT PRESENT D1 - LANE QOSURE 4 - INTE.RMITTENT OR MO\IING WORK D1 - BEFORE mE FIRST WORK ZONE WARMf'Kl SIGN 4 - AcTiVITY MEA

RELATED (OFR:::t:I>JV~ 2 - lANE SHIFTI CROSSOVER 5 - <mER 2 - ADVAn:-EWAANJf'KlMEA 5 - T ERMINA TlON MEA

0 LAw OI=ORCEMENT PRESENT 3 - WORK ON SHOULDER OR MEDIAN 3 - TRANSITION MEA (Ve-t:uO....Vj

NARRATIVE

Unit 02 was southbound on S Washington St. Unit 01 was northbound on <!' .z. ......S Washington St. when unit 01 struck mirrors with unit 02. "il> I% ~ N

'?:> q'<{? s., CJ C<).

No Name St.

~

~ VI :::T s· '" 0'

OJ

REPORT TAKEN By o SUPPLEMENT (Cc-..tCTlONOR ADoTlON lOAN

SO

• POlICE AGeNCY o MOTORIST ElasI1HO REPOI'Il So.rr TO ODPS)

DATE CAAsHREPORTED ITIME CRASHREPORTED Io.SPATCH TIME ARRIVAl TIME TIME QEARED I<mER INVESTIGATIONTIME TOTAl Mwres

04/30/2016 1728 1731 1733 1742 20 31

OFfiCER'S NAME" OFFICER'S BADGE NUMBER CHECKED By

Genet, Stephanie 127

-, uNIT ._,~o,..

ILOCAL REPORT NUMBER

I 16 MPD 0651 UNIT NUMBER Io._R N""'E, lAsT. F,RST. M'DOlE ( 0 S""'EAs DRIVER) I OwNER PHO'" NUMBER DAMAGE ScALE DAMAGE MEA

~ FRONT

1 ' , os~o-~OwNER Aoooess: Orv. STATE, lJp OS""E As DRIVER )

1 · N"",

, OH -J..----.JI­LP STATE IWCENSE PLATE NUMBER VEHICLE IDE N'TlFICA nON N W ,OER r OccUP-~

2· MINOA .,.--. /

3 - F UNCTIONAL • I 0 I J

VEHICLE YEAR IVEHICLE MAI(£ I VEHICLE M ODEL IVEHIClE woo 0 Ford BLK

4 - D.sABUNG

c~G1~o PROOf OF I'NSURANCE CoMPANY r oucy NuMBER ITOY"'D By 9 - Ur-I(NO'M'-IINSURANCE SHOWN

CAARIER NAMe. ADDRESS. errv, STATE , lJp ICARRIER PHoNE

US DOT VEHICLE WEIGHT G'V'NR/OONR. CARGO BODY Tvpe TRAFFICWAY DESCRIPTlOND1 - Less TH.A.N OR EOUAl TO 10K Lss 001 • No CARGO Booy TvpElNoT APPLICASl 09 • POLE [1] 1 - T wo.WAY NoT DV10ED 2·10,001 T026,000K Lns 02 • BuSi VAN (9-15 SEATS. INC DR,VER) 10 - CARGO T_ 1 2 - T WO.WAY: NOT OI\11OEo. CoNTINUOUS leFT TURN l...o.Ne

HM PLACARD 10 NO. 3· MORE THAN 26,000K Las. 03 • Bus (16' SEATS. INC DR,VER) 11 • FlAT BEO 3 - T wo.WAY.DvtOEO. UNPROTECTED(PAINTEDOR GRASS ~4Fq ME DI A

04 - VEHICl.£ TO'MNG ANoThER VeHICLE 12 · DuMp 4 - T 'NO.W AY. DV1OEO. POSITIVE MEDIAN BARRIER05· LOOQNG 13 - CoHcRElE M IX ER

l-lAzAAoous MATERIAL 06 - If>ITERMODAl CoNTAINER Cti.A.sIS 14 - AlITa TRANSPORTER 5 - OnE.WAY T RAFFICWAV

HM CLAss 0 ReLATED 07 - CARGO VAN<ENClosEO Box 15 - GARBAGE IREFUSE HIT I SKfPUNIf•NUMBER 08 - GRAIN. CHIPS. GRAVEL 99 - OTHER/UNKNOWN

NoN. ~...1()f()RlST LOCATION PR IOR TO IMPACT TYPE OF U SE lMTTYPE

0

01 - INTERSECTION· M ARKf.D CROSSWAl D [ill P ASSENGeR VEHICl£S (u:ss 1'1'WI9PASSEN:>ERS MEOIHeAvv TRUCKS OR CoMBO UNTS " lOt< L8S BusNmtJ.,40(9 OR MORE INCLUDING DRIVER) 02 - INTERSECTION· No CRoSSWAU< 0 1 - Sus ·CoMPACT 13 - SiNGlE U,..T TRUCK OR VAN 2Ax.i.E. 6 TIRES 21 - BusNAN (9-15 SU.TS I~ oP:!YER)03 - INTERSEcnON OTHER 1 • PERSOtW. 02 - CoWACT 22 • Bus (16' s...~. k~)04 - M fOOLOO< • MARKEO CROSSWALK 99 - Uf'.KN<JoIM.I 03 - MiD SIZE

14 - SiNGLE UNIT TRUCK; 3-+ AXLES

05 - T RAVEL l..ANe . OTHER L OCATION 2 - CoMMERCIAl 15 ­ SING..E UNlTRUCKfTRAlL£R N ON-MoTORIST

OR HIT/SKJp 04 - FULL SIZE 23 - ANIMAl WIT"H RIDER 06 • BoCVCl£ t....;., 3-GoVERr.l.AENT 05 - MiMVAN 16 ­ TRUCK/TRACTOR (BoBTAIL) 24 - ANIMAl WITH BUGGY. WAGON. SURREY 0 7 - StK>uLDERlROADSIDE 06 - SPoRT UTILITY VEHICLE

17 ­ TRACTORISEMI.TRAILER

08 - SIiDEWAlK 07 - RCKUP 18 · TRAC'TQRJOouBLE 25 • BCVCwPEQACYCUST

19 - TRACTOR/TRiPlES 26 - PeoesmlANlSKATER09 - M EOIJl.Nl'CROSSING 1Sl.J\M) o IN EME RGENCY 08 - VAN 20 - OTHER MED/HEAVV VEHICLE 27 - OTHER N OH-MOTORIST 10· DRIVE WAY Access RESPONSE 09 - MOTORCYCLE 11 - SHARED-Use PATH OR TRAIL 10 ­ MOTORIZED BICYCLE 10 I1 2 - NON-TRAFFICWAY AREA 11 • SNCWMOBlWATV HASHM PLACARD 99 • OrnERIU""",,,,, 12 ­ OTHER P ASSENGER V EHIClf

SPECiAl F UNCTIONOl - Not-E 09 • AMBULANCE 17 ­ FARM VEHICLE M OST DAMAGED MEA AcrION

0

02-TAXI 10 - FIRE 18 ­ FARM EOOIPMENT

~ 01·No", 08· LEFT SlOE 99 - UNKNOWN ~ 1 - NON- CoNTACT03 - RENTAL TRUCK (OvER 10K LBS) 11 - HIQ1Y/AY/MAINTENllJ..CE 19 ­ M OTORHOME 02 - CENTER FRONT 09 - LEFT FRONT 3 2 · NON-ColLISION

04 - Bus· ScHOOl (PuBLIC OR P RIVATE) 12 ­ MIUTAAY 20· GOIlFCART 03· RiGfTFRONl 10 · T OPAI'«) W 1MXNfS 3 - STRIKING05· Bus. TRANSIT 13· POUCE 21 - T""'N IMPACT ME 04 - RiG<TSlOE 11 - U r-.oeRCARRIAGE 4 - STRUCK06 - Bus. CHARTER 14 - PuBLIC UnUTV 22 - OrnER (E.J-L..... " NAAR.o. ...,.£)

~ 05 • RiG<T ReAR 1 2 - L OAOlT RAlLER 5 - STRIKlNGlSTRUCK

07 - Bus· SHUnLE 15 • 0rHaI Goval_", 06 • REAR CENTER 13 · TOTIoL(Au AAEAS) 9 - UfI.I<NOWN08 - Bus. OTHER 1 6 - CoNsTRucnON E OIP. 07 • LEFT ReAR 14 - OTHER

PRE ·CR_AcnONS

[QI] rv\oTORIST NON-MoTORIS T

01 - STRAIGHT AHEAD 07 ­ MAKING U-TURN 13 - NEGOTlATINOA CuRVE 15 ­ ENTERING OR CROSSING SPECIFIED LOCATI O 21 - OTHE R N ON- M OTORIST ACTION

02· BAcKING 08 - E NTERING TRAFFIC lANe 14 - OTHER MOTORIST Acno 16 - WAI....KING,RufflNG. JOGGING, PLAYING. CYCLING

03 - CHAAONG lMEs 09 - LEAVING TRAFFlC ~ 17 ­ W ORKING 99·U"""""", 04 . OveRTAKlr«l!PASSlNG 10· PARKED 18 ­ P USHING VEHICLE

05 - M AKING RU:i-1T TURN 11 - SU:W'/INCOR STOPPED IN T RAFFIC 19 ­ APPROACHING OR lEAVING VEHIClE

06 - MAKING LEFT TURN 12 ­ DRIVERLESS 20 - STAl'ONG

CoNTRIBUTING CIRCUMSTANCE VEHIClE DeFECTS

P RIMARY M OTORIST NON-MoTORIST o 01 • TuRNSIGNAlS

00 01· NONE 11 - IMPROPE R BACKING 22· NONE 02 - HEAD lAMps02 - FAILURE TO YIELD 12 · IMPROPER START F ROM PARKED P OSITION 23 - IMPROPER CROSSING 03 . T PJL l.AMPS 03 - RAN REO LIQiT 1 3 - STOPPED OFt P ARKED ILLEGAllY 24· DARTING 04 • a.MES 04 • RAN STOP SIGN 14 - OPERA nNG VEHICLf IN NEGUGENT MAt..NeR 25 ­ L YlNGNOIOA llI.EGAI..lY INRoAOWAY 05 • STEERING

SECONQAAY 05 - ExCEEDED SPEED UMIT 1 5 - S~RINGTO AVOID (DuE TO Ex"reRNALCoto"rcONS) 26- F ALURE TO YIELD RrQ-fT Of WAY 06 . T IRE BLOWOUT

0

06 • UNSIIFE SPEED 16 - WROt¥:. Sloe.MIRONG W AY 27 - NOTVISlau: (DAAK Ctonm..a.) 07 - WOAN OR SucK TIRES 07 ­ IMPROPER T URN 17 ­ F AlURE TO Com-AOl 28 - INAnErffiVE 08 - T RAILER E OOIPMENT DEFECTIVE 08 ­ LEFT OF CENTER 18 • VISION OssTRUCTION 29 - FAILURE TO OBey TA~IC SeN; 09 ­ M OTOR TROUBlE09 - F ou.oWEO T oo CLOSELY/ACDA 19 · OPERATING D EFECTIVE EOOIPMENT ISlC>W.SIOFFI~R 10 ­ D,SABL ED F ROM P RIOR AccIDENT

99· UNKNCl"" 1 0 - IMPROPE R l.NE CHANGE 20 - L OAD SHlFTlNCilFAWNGlSPILUNG 30 - WRONG SIDE OF THE R OAD 11 - OTHER DEFECTS iPASSINGIOFF R OAD 21 - OTHER I MPRoP£R ACTION 31 - OTHER NON-MOTORIST AcnON

SeOOENCE OF EVENTS ~Qti. CQU.!ii!~ ~~tUa

1112] 20 30 4 0 50

6 0

01 - OveRTURN/ROLLOVER 06 - E OOIPMENT FAILURE 10 • CRoss MEo/AN 02 - F IREtExPLOSION (D'-"""" TIJlC.eIWCEF....~.En:::) 11 • CRoss CENTER WNE

F'RST [I] M~' [I] 03 - IMMERSION 07 ­ SEPARATIONOF' UNITS OPPOSITE DIRECTION Of' T AAVEL

HARMFUL HARM"'L 1 99· UNKND"" 04 - JACKKNIFE 08 - RAN OFF ROAD R,GHT 12 ­ Dov.-H1Ill. R UNAWAY

EVENT E VENT 05 - CARGOfEoolPMENT Loss OR SHIFT 09 • RAN OFF ROAD LEFT 13 ­ OTHER NON-Coi..J..lsION

COLl.!~~:i!1TH EI~"Q QW,!;;T

CQII ISJOO ~ll:! EEB SQt::l ~ct:lI!;:I.f QB QI1!"~ ~QT EI~ED: 25 ­ IMPACT ATTEMJATORICRASH CuSHlOti03 - M EDIAN CAaLE B ARRIER 41 - On-rER P OST. P OLf 48 ­ T REE

14 - PEDESmlAN 21 - PARKED MoTOR VEHICLE 26 ­ B RIDGE OveRHEAD STRUCTLflE 34 ­ M EDIAN GuAAOFlAIL BARRIER OR SuPPORT 49 ­ F IRE H YDRANT

15 ­ P EDAlCYClf 22 - WORK ZONE MAINTENANCE E OOIPMENT 2 7 - BRIDGE P IER OR ABUTMENT 35 - M EDIAN CoNcAETE B ARRIER 42 - CuLVERT 50 - W ORt< ZONE MAiNTENANCE

16 - RAlLWAyVEI-UCLE (T1WN. Et4M) 23 - STRUCK BY FAU.ING. SHIFTING CAF1.CO 28 ­ BRIDGE PARAPET 36 - MEDIAN OTHER B AARIER 43 • CuRB E OVIPMENT 17· AIooMAL · FARM OR ANvTHlt-IG SeT IN MonON BY A 29 - B RIDGE RAIL 37 - TRAFfICSiao.r P OST 44 - DrTCt1 5 1 - WAll. B VII.DtNG. T UNM:L

18 • AIooMA/. . DEER MOTOR VEHICLE 30 - GUARDRAIL F ACE 38 - OveRHEAD SIGN P OST 45 - EMBAt«MENT 52 ­ OTHER F IXED OwECT

19 • AIooMA/. .OTHER 24 - OTHER M OVABLE OBJECT 3 1 - GUARDRAILENO 39 ­ LIQ1lILVMlNAAlES SUPPORT 46 - FENCE 20 ­ M OTOR VEHICLE IN T RANSPORT 32 - P ORTA6L£ BARRIER 40 - UnuTV POKE 47 ­ MAILBOX

UNIT SPeeD P OSTEO SPEEO T RAFTtc CaNTHOl U ....T DRECTION

[QI] 1 - NORTH 5 - NORTHEAST 9 - UNKNOWN

20 25 01 - NoCol'ImOLs 07 ~ RAlLROt\O CROSSBUCKS 13 ­ CROSSWALK U NES FROM ~ To [] 2· ScurH 6 - NooTHWEST 02· STOPSI"" 08 . R AlLROAO F lASHERS 14 - W AlI<JD::m'T WALK 3 - EAsT 7 • ScurHEAST 03· VlEwSI"" 09 . R AlLROAO GATES 15 ­ OTHER 4-WEST 8 - 5ouTHw1;ST

o STATED 04 - T RAFfiC SI~ 10 ~ CosmUCTION BARRICADE 16 - N OT REPORTED

05 - TRAFFIC FLASHERS " - P ERSON (FLAGGER. OFFICER • EsTIMATED 06 • Sa<OO< ZONE 12 ­ P AVEMENT MARKINGS

).L_c·( uNIT ILOCAL REPORT NUMDER

._.....-:::::::"--- .-.. I 16 MPD 0651 UNT NUMBER I o.....;R NAME, LAsT.F,RST. MIDDLE ( 0 SAME As DR,llER) I o.....;R PHO"" NUMBER DAMAGE ScAlE DAMAGE MEA

2 Fortune, Jeffrey, P ~ FRONT

419-368-4235

D~~D-'~ONNEA ADooess: Ow, STATE. ZIp DSAMEAs DR,llER) 1· NOM'

117 Georgia St, Ashland , OH, 44805 I­ J---.....II­LP STAT" I~'CENSE PLATE NUMB" VEHICLE IOENTlFICATION NUMBER rOccUP-~

2· MiNOR r--/ OH GSQ6628 3GCRKREA8AG121458 3 - FUNCTIONAL • I 0 I J

VEHIct£ YEAR IVEHIClE MAKE I VEHICLE MooEL IVEHIClE CocOA

2010 Chevrolet Silverado C1500 ­ SC1 DBL 4 - DSA8Uf\KJ

o~fn1~• PROOf OF I:NSUR~E CoMPANY r ouev NUMBER IT"""D BYINSURANCE 9- UM(.N()\o\'N

SHOWN Grange Insurance PA1213250

CARRIER NAMe. ADDRESS. CflY, STATE, Zip 1CARRIER PHooe

USOOT VEHICLE WeiGl-iT G'\J'INRJGONR CARGO BoovTYPf: TRAffiCWAY DESCRIPTIOND1 - Less THAN OR EOUAl TO 10t< Lss []I] 01· No CARooBoDVTYPElNoT ApPlICA&. 09· POLE [1] 1 - T WO·WAY. NOT DWlOED

HM PLACARD ID NO. 2· 10,001 TO 26,000. Las 01 02· BuS/V.... (9-15 SEATS. INC DRIllER) 10· CARGO TAN< 1 2 - T WO·WAV. NoT DlVlDEO. CoNnwous LEFT TURN lNE 3· MORE T"",,26.000. Los. 03· Bus (16+ SEATS, INC DRIllER) 11 - FLAT Beo 3 - T wo-WAY, D VlOEO. UwROTECTED(PAlNTED 00 GRASS >4FT) MEDIA

04 - VeHICLE T OWING ANon-tEFI VEHICLE 12 - DuMP 4 - Two-WAY, DVlDED, POSITIVE MEDIANBARRIER05 - LQG(ljNG 13 - CoNCRE TE MIXER

HAzARDOUS MA~RIAL 06 - INTERMOOAL. CoNTAINER CHASIS 14 - AuTO TRANSPORTER 5 - CJr.E.WAY TRAFFICWAY

HM Cu.ss 0 RELATED 07 - CAROOV-ENClOSEOBox 15 - GAR8AGE IREFUSE HIT I SKIP lJHTNUMBER 08 - GRAiN. OtIPS, GRAveL 99 -OmER/l...INKNolMII

0

NON-MOTORIST L OCATION PRIOA TO IMPACT TVPEOF USE U .... TYT'E

0

01 -ltfTERSECTION· MARKEOCROSSWAl

~ [QZJ PASSE..,.. VEtOOl£S(LESS Tl<AN9PASSENGE.S MElliHeAw TRLJCI(SQR Co""" U~ .1OK UlS BusN...u.0(9 OR MORE INClU"''''' DRIVER)02 -It-ITERSECTION. No CROSSWAlK 01 - SuB ·COMpACT 13 ­ Sit.G..E U"'T TRUCK 00 VAN 2AxLE. 6 TIRES 21 - BuS/VAN (9-15 So..l"S IN:::~)03 - ItfTERSECTION OrnER 1 - PeRSONAL 02 · CoMPACT 22 - Bus (16+ s....~ I~ 0....)04 - Mi08LOCK . M,"UI..EO CROSSWALK 99 - U"""""" 03 • M<> SIze

14 - SINGlE UNfT TR UCK. 3+ AXlES

05 - T RAVEll.ANe. OTtteR L OCATION 2 - CoMMERctAL OA Hn/$t<IP 04 • Full. 54ze 15 - SiNGlE U"'T TRUCK I TRAILER NoN-MOTORIST

06 - S.CYCl.£ lANE 16 ­ T RUCK/T RACTOR (BOBTAIL) 23 - /lNMAJ... WrTH RIDER

3-GoIlER_NT 05 · MNlVAN07 - 5How>ERlRoAOSlllE 06 - SPoRT UnUlY VEHlCl.E

17 ­ TRACTORJSEMI.TRAJLER 24 - AHMAJ... Wlm BUGGY. WAGON. SURREY

08· SU)£'HALK 07 · PICKUP 18 ­ T RACTORJDouBLE 25 - S.CYCWPEOACYCUST

19 ­ T RAClORITRIPLES 26 - PeDESTRIAWSKATER09 - MEDlAN,OWSSlNG ISLA>Il o IN EMERGENCY 08 • V .... 20 - OTHER MEntHEAVY VEHICLE 27 - OTHER NON-MOTORIST10 - DRIVEWAY AccESS

RESPONSE 09 - MoTORCYCl.£ 11 - SHARED-USE P ATH OR TRAIL 10 - MoTORIZED BicycLE.

10 112 ­ NON-TRAFFICWAY AREA 1 1 • SNGWMOOLEiATV HAS HM PLACARD 99 - OT>ERlU""""YoN 1 2 - Oll1ER PASSENGER VEHICLE.

$PeCl.-.L F uNCnONOl - NOt£ 09 - AMBUI.ANCf 17 ­ FARM VEHICLE M OST DAMAOEoAREA AcTION

[]I] 02 - TAXI 10 ­ FIRE 18 ­ FARM EOUIPMENT @[J 01- NONE 08 ­ LEFT SIDE 99-U~NO~ iii 1 - NoN- CONTACT03· ReNTAl TRUCI< (OIlER 10K L8S) 1 1 - HiGHWAyiMAlNTENANCE 19 ­ MOTORHOME 02 - CeNTER FRONT 09 - L EFT FRONT 2 - NON-CowSlON04 - Bus. SD-4OOL(Pueuc OR PRIVATE) 12 - MiUTARY 20 - GoLF CAR T 03 - RlOHT FRONT 10 ­ T op AND WlroKX»IS 3 - STRIKING05 - Bus . TRANSIT 13 - PoueE 21 - TRAIN IMPACT ARE 04 - R,OHT 541lE 11 - U~ERCAARIAGE 4 -STTlUCl<06 - Bus· CHARTER 14 - Pusuc UTiUTY 22 - OTHER (~ltIN.oAR.o.T'1VE)

~ 05 - R,Ot" REAR 12 ­ LOAD/T RAILER 5 - STRIKtNGlSTRUCK

07· Bus· SHllTTLE 15 ­ Oll1ER GJVE.R~ENl 06 • REAR CeNTER 13 - TOTAl (AlL AREAS) 9 - Ur«NO'M'I08 - &Js. Oll1ER 16 - CoNsTRUCTION EOIP. 07 • leFT REAR 14 -OmER

PRE · CRASH ACTIONS

[]I] MaTOAIST NoN-MOTORIST

01 - STRAIGHT AHEAD 07 - MAKING U-TURN 13 ­ NEGOTIATING A CuRve 15 • ENTERING 00 CROSSING SPECIFIED LOCATIO 21 - Oll1ER NoN.MOTORIST AcnON

02 - BACKING 08 - ENTERING TRAFFIC lANE 14 - OTHER MOTORIST Acno 16 • WN.I<JNG.RuNNING. JOGGINCl.. PLAVlNCl.. CYCLING

03 - CHAN(;jNG lANEs 09 - LEAVING TRAFFIC lANE 17 ­ WOR"''''''99 - UN<N()"'" 04 - OvERTAKlNGlPASS!NG 10 ­ PARKED 18 · PUSHING VEHICLE

05 - MAKING R[(:~1T TURN 1 1 - SU:W.....NG OR STOPPED IN TRAFFIC 19 • APPROACHING OR W\lTNG VEHICt.E

06 - MAKING LEFT TURN 12 ­ DRIVERLESS 20 - ST.,..,,"'"

CcwmI8UTING ORCUMSTAflK::E VEHICLE DEFECTS

PRIMARY M OTORIST NON-MOTORIST o 01 - TURNSlaw..s

[]I] 01- NONE 11 - IMPROPeR BACKING 22- No,"" 02 - HEAD lAMPS 02 ­ FAILURE TO YIELD 12 ­ IMPROPER START FROM PARKED P OSITION 23 - IMPROPeR CROSSING 03 - TAlL lAMPs 03 - RAN REO LIGlT 13 ­ STOPPED 00 PARKED IU£GA.U. Y 24· DARTING 04 - BRAKES 04 - RAN STOP S,GN 14 - OPERATING VEHICLE IN NEGUGENl MAtH:R 25 - LV1NG.tIH)K)R IU£GAL.LYIN R OAOWAY 05 - STEERING

SECONDARY as - ExCEEDED SPEED UMIT 15 - SWERING TO AVOlO (DuE TO ExTERNAl CoP'OTIONS) 26· F AlURE TO YIELD RIGHT OF WAY 06 - TIRE Bu:)!,\IOU1

0

06 • UNSAFE SPEEO 16 - WRCJtIGSIDEJWRCJtIGWAY 27 • NOT VISIBLE (DARt< Q.OTHING) 07 - WORNOO &....icK TIRES 07 - IMPROPER TURN 17 - F AlURE TO CoN"mOL 28· INATTENTIVE 08 - TRAILER EQUlPMENl DeFECTIVE 08 - LEFT Of CENTER 18 ­ VISION OBsTRUCTION 29· FAILURE TOOoeY T RAFFIC &cxs 09· M OTOR TROUBlE09 - Fou..Q\oVEOToo CLOSELYIACDA 19 ­ OPERATING DeFECTIVE EQUIPMENT ISlGlALsiOFflCER 10 ­ DISABLED F ROM PRIOR AccIDENT

99 - UN<N()WN 10 • IMPROPER lANE CHANGE 20 - LOAD SHIFTlNGiFALlINGISPIWNG 30 - WRONG SlOE OF THE ROAD 11 - OTHER DeFECTS rPASSINGIOFF R OAD 21 - OrnER IMPROPER AcTION 31 - OTHER Noo-MoTORIST ACTION

SEOUENCE OF EveNTS ~CotII~Qt:fE~!:fHi

1~ 2 0

3 0

4 0

50 6

0 01 - OVERTURN/RouoVER 06 - EOUIPMENT F AILURE 10 • CRoss ME[)<AN 02 - FlRfJExPt..OSION (Bl~TIIlI1. 0"",,o(Z F ...... uoot'.. t"c) 11 - CRoss Cet<TER I..J,""

FIRS'T m M~lm 03 -IIoWERSlON 07 - SePARATION OF U"'TS OPPo.s.ITE DIRECTION OF TRAVEL

HARMFUL 1 HARMFUL 1 99-U_ 04 - JACJ<JWFE 08 • RAN OF, ROAD Fl."", 12 - Do~Ll RUNAWAY

EIlENT EIlENT 05 - CAAGOIEouIPMENT L oss 00 SHIFT 09 - RAN Off ROAD Len 13 • OTHE. NON·CoWS"'N

CouI§!~~ll1EIXIii!2 QIl:.IIii~ CQlII~QtJ:i:lIJtj EE8~ ~fl:!lQ EQB Qa./ECI ti=!I E'~EQ 25 - IMPACT ATTEh\JAT~ASH CuSHIoM3 - MEDIAN CAoLE BARRIEA 41 - OTHER P OST. POLE 48 - TREE

14 - PEDESTRIAN 21 - P ARt<ED MoTOR VEHICl.E 26 ­ BRIDGE OvERHEAD STRUClUlE 34 - MEDIAN GuARDRAIL BARRIER OR SUPPORT 49 ­ FIRE HvoRANT

15 . P'EOALCYCLE 22 - WOOK ZeN: MAINTENANCE EOUIPMENT 27 - BRIDGE PIER OR ABUThlENl 35 - MEDIAN CoNcRETE BARRIER 42 - CuLIlERY 50 - WORK ZOfo.E MAiNTENANCE

16 - RAlLWAV VEHlClf (TA.oIH. E"':"E) 23 - STRUC1< BY F AWNG. SHIFnNG CARGO 28 ­ BRIDGE PARAPET 36 ­ MEDIAN OrnER BARRIER 43 ­ Cu.B EOUIPMENT

17· /lNMfjL, . FARM OR Anv"THING SET IN M o nON BY A 29 - BRIDGE RAIL 37 - TRAFFIC SIGN POST 44 - OrTCtf 51 - WAlL. BUIlDING. TUt'ONEL

18 ­ /lNMAl . DEER M OTOR VEHICLE 30 - GUARDRAIL FACE 38 - OVERHENl StGN POST 45 - EMBNO<MENT 52 - OrnER FIXED OBJECT

19 - AAMAL ·OTHER 24 - OTHER MOVABLE OBJECT 31 - GUAROOAlLE~ 39 ­ LI01TILuMINARIES SUPPORT 46 - FENCE 20 - MOTOR VEHICLE IN TRANS~T 32 - PORTAeLE BARRIER 40 ­ UTILITY POLE 47 - MAILBOX

U,.T SPEED POSTED SPeEO T RAFFIC CoNTRCt. UNIT DIRECTION

[]I] 01 - No CONTl<OLS 13 - CROSSWAlK UNES 1 - NOATH 5 - NORTHE.AST 9-l.Jt..t<NO~

15 25 07 ­ RAu..AOAD CRoSSDUCKS FROM m To ~ 2· SoUTH 6 - N ORlH'tVEST 02 - STOP 54GN 08 - RAILROAD FlASHERS 14 - WAwD,,,.... W"'" 3 - EAsT 7 - SouTHEAST 03 ­ YIELD SGN 09 ­ RAILROAD GATES 15-0THER 4-WEST 8 - $ouTHweST

• STATED 04 - TRAFFIC SIGNAL 10 - CoSTRUCTION BARRICADE 16 ­ NOT REPORTED

os -TRAFFIC FLASHERS 11 - PERSON (FLAGGER. OFFICER o ESTIMATED 06 - ScHOOL ZO>E 12 - PAVEMENl MARKINGS

M N M o .-.,~, OTORIST I ON­ OTORIST I CCUPANT ILOCAl REPoRT NUMBER

I 16 MPD 0651 UMT NUMBER I NAME , lAsT. F'R ST. MDDLE DATE Of BIRTH /la

I~R F· FEMAlE

2 Fortune Jeffrey, P 10/19/1966 49 M • MALE

Aoooess. Crv, STATE, ZIP IComACT PHONE· ,NQUDE AREA CODE

j 117 Georgia St, Ashland, OH, 44805 419-368-4235 o INJURIES INJURED TAKEN By EMS/laNC' MeDICAl F AClUTY INJURED T AKEN To SAFElY E OVIPMENT U SED OOTCOMpu SEAllNG P OSInON Am BAG U SAGE E JECTION RAPPED

z 7.

OJ OJ [J MOTORCYCLE [ill OJ OJ OJ0

E 04 HELMET

~ OL STATE ~OPfRATOR weENSE NUMBER O~le~:D Ie ~~ Illi mN

I m~DRUGSu_mD INol TEST5TAWS m~TESTT~ I~OH~ TESTV~UE DoUG TEST 5TAWS I DRuG TEST TWE 0

OH NW549232 1 1 OFFENSE CtARGED ( e Loc~ CooE) OFFENSE DeSCRIPTION 10TATKlN NU""ER HANDS· FREE Ifu~R DSffiOffi B, e DEvlee

UseD

UNT NUMBER INAME' lAsT. F'RST. M'ODLE DATE Of BtRTl-I /la

IEr

F • FEMALE

M· MALE

AooRess. Crrv.STATE. ZIp IComACT PHONE . ,NQUDE AREA CODE

!!l

2 a INJURIE S INJURED TMEN By EM5/laNCv MeDiCAlFAC1UTY INJUREOTMEN To SAFETY EQUIPMENT Useo OOT COMPUANT EATlNG P OSITION AIR BAO USAGE EJeCTION RAPPED

~ 0 0 D MOTORCYCLE D 0 0 0HELMET ; gOLSTATE 1000RATOR weeNSE NUMBER lrss le~,o Ie ~~ I [fON IDwDoUG5u~=orD TEST5TArus 0 TESTT'fPEIAW~~ TESTV~UE DoUG TEST 5TATUS I DRUG TEST TYPE

C>FFENSE OLAAGEO ( e Loc~Qooe) OFFENSe DeSCRIPTION ,lOTAnON NUMBER HAM>s-FREE 16

R DSnRao Bve DEvICE

USED

INJURIES INJURED T MEN By SAfETY EQUIPMENT USED 99 • iJNI<NowN s...ETY EOUIPMENT

1 ~ No INJURY J NoNE REPORTE 1 ~ NOT T RNoISPOATEO J MoTORIST NOH-MoTORIST

2· POSSIBlE T REATa> AT SceNe. 05 - CilLO ReSTRAlNTSYSTEM·FooWNID FAONQ 09 • NON: U= 12 • RauCl1\lE CoAn""3 - NON.INCAPACITATING 2·EMS 01 - NotE Useo . VEHtCL,E OccUPANl

4 - IN::.APACllATING 3· Pouc. 02,51""""" Bf.lTONev USED 06 - CHIlD RESTRA5Nf SYSTEM-REAR FAaNG 10 • HEUIET USED 13 • L,,,,,",,,, 5- FATAl.. 4-0n<EA 03 • lAP BELT ONeV UseD 07 • BoosTER s.., 11 • PRoT<enve PIIOS USED 14· OTl1EA

9· UO«NC>M< 04 • 5 HOUlDEA AHo lAP BELT 0..v USED 08 - HEUIET USED (EL.aOWS, KIa&. Et.:)

SeATING POStTION AoR&GU...,.

01-FRONT. LenSOE(Uo'IDIIar.tr:~) 07 - T,lAo . LEFTSfOE ('Mo1'C*:<'CLESuCNI) 12 • PASSENGER IN UNENClOSED CARGo AR£A 1 - NOT DEPlOYED

02 • FRONT· M,DOl£ 08 - T "RD· M>OOLf 13· TRAILOIO UNT 2· D£PloYED FRONT 03 • FRONT . RooT SoDE 09 ­ THIRD· ROil SIDE 14 - RfDlOO ON VEtttaJ: ExTERIOR (Nott-T........ollNr) 3·D£Pl0VE05ooc 04 • s.co.oo . LEFT So"'_P_1 1 0 - SlEEPER. SEcTION or- CAn {T1lUC1I1 15 • NOfI.MoTORIST 4 • DePlOYED Ben< FRONT/SoDE 05 . 5tCONO . ""DOLE 1 1 • PASSENOER IN OTl1En ENco....o CARGo""EA 16·0TT<EA 5 • NoT APPucA8&.. 06 • 5tCONO . Room Sooe (t*»TtIk.....:i UN' SU01 .... " BIn. Po.-vP ..1\fc.u» 99· U_ 9 • D£PlovueNr iJNI<NowN

EJECT10N TR.N'PED OPf.RATOR LICENSE ClAss CONDmON ALCOHOLIDoUG 5USPECTED

1 - NoT EJECTED 1 • NOTT.....D 1· Cv.ssA 1 ~ APPAAfNlLY NoRM...... 5· FeuAluEP, FAINTED, FAT10Ut 1. NoNE 2 ~ TOTALLY EJeCTED 2 - EXTntCATEOBY 2- OlAs.B 2 - PHVSfCAlIMPAIftMENT 6 - UM>ER THe If#lUENCE OF 2 • YES. ALC<JHO<. 5usP<cTEO 3· PARn....v Ekeltc MECtWOCAL MeANS 3· Cv.ssC 3· Eo.tOT"""- (0.........0, Analv, DsT\JROE Mffil<ATlONS. DouGS. ALCOHOl 3 ~ YES .Hso NoTlMPAIREO

4 • NoT AA>t.oc.8l£ 3 . EXTRICATED BV 4 - REGuLltR Q..Ass (OMoc-o'1 4 ·IUNE" 7·0-. 4 - YES -DRUGS SuSPeCTED

NOtrMECIW<ICAL MeANS 5 • MCiMOPEO.Qtu: 5 • Y.s .ALCOHOl. AND Douas 5usP<cTED

ALC:OttOL TtST STArus ALCCt1Ol. TEt'lTT'r'f"E DRUG TEST STATUS DRooTESTT'r'PE Do""" DSlRACTED Bv

1 • NOI'£ GIvE. 1· NoNE 1 • NONE GIvEN 1· NONE 1 - No DslJlACTtON REPORT1:D 6 • OnEA INSIDE THE VEHICI.£ 2 - TEST REFusED 2· &.000 2· TEST RefUSfO 2-&'000 2· f'Hoo.E 7· ExTERNAl DIsTRACTION

3 • TEST G_. Com_....nro SAMPt.£lUNUSAIll 3 ·UR,,., 3· TESTGlvEN. Com_nro5AMPu/U~ 3· URI'" 3 - T.XTING lEMA""'" 4 - TESTG:vi:N, RE6lA.TSKNO'Afl 4 - BREATH 4· TESTGVEN. R.SUlTS~ 4· OTH.R 4 - ELcmONC eo...l.NCATtON DeVICE

5· TEST GvEH. ReSlA.TS \Jr«HowN 5·0Tl1ER 5· TesTGVEN. RESll.T5~ 5 • OT.... fucrnONC 0.""", (N.<.~'n()IrfDt.w:f,fWIIo. OW)

UNT NUMBER I NAME ' lAsT. F'RST. M>D~ 1DATE'" B,Rn< AGE

lEI" F - FEMALE

M - MALE

ADDRESS. ON.STATE. lJP ICoNTACT PHON; . INCWDE AREA CODE

INJURIES INJURED TN<EN B y EMS/laNCv M EDICAL FACILITY INJURED T MEN To SAFETY EOUIPMENT U seo OOT SEAnNG Posmcw AlR BAQUSAOE EJECnON TRAPPED

0 0 CCot.wUANT D 0 0 0MoTORCYCLE

HELMET

U.n NUMB'" JNAM E' lAsl . ~'RST. M,oOLE IUATE '" t:I'RTH IAGE

loR F · FEM~ M ~ MAlE

Aoooess, Crrv.STATE. ZIp IComACT f'Hot.E . ,NQUOE AREA CODE

~ INJURIES INJURED T MEN By EMS /laNGV MEDICAl. FACIUTY INJUREO TAKEN To SAFETY E OUIPMENT USED OOT SEATING POSITION ArA BAG USA.GE E..ecnoN TRAPPED

0 0 [J CoMPUANT D 0 0 0MoTORCYCLE

HELMET