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LOCATION 1ST EVENT TRAFFIC CONTROLo GORE 0 OTHER 0 ADVISORYSPEED 0 NO PASSINGZONEo MEDIAN PROPERTY SIGN 0 OFFICEROR FLAGMANo ON ROADWAY 0 CENTER LINE 0 R.R.GATESo OUTSIDESHOULDER,LEFT 0 CURVE SIGN 0 R.R.SIGNS OR SIGNALSo OUTSIDESHOULDER,RIGHT 0 FLASHINGLIGHT 0 SCHOOLZONE SIGNSo SHOULDER Q MEDIAN 0 STOP & GO SIGNALROADWAY CHARACTER :joADWAY SURFACE ROADWAY CONDITIONo CURVE& GRADE 0 STRAIGHT & GRADE 0 ASPHALT 0 DRY 0 OTHERo CURVE& HILLCREST 0 STRAIGHT & HILLCREST 0 CONCRETE 0 ICEo CURVE& LEVEL 0 STRAIGHT & LEVEL 0 GRAVEL 0 SAND,MUD,DIRT,OIL,GRAVELo OTHER 0 SNOW/SLUSHo WET

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MANNER OF COLLISIONo ANGLE 0 SIDESWIPE,OPPOSITEDIRECTIONo BACKING 0 SIDESWIPE,SAME DIRECTIONo HEADON 0 SINGLEVEHICLEo OPPOSINGLEFTTURNo REARENDo REARTO REARROADWAY TYPEo COUNTYROADo FEDERALo FRONTAGEROADo INTERSTATEo LOCALSTREETWEATHERo BLOWINGSAND,SOIL,

DIRT,SNOWo CLEARo CLOUDYo FOG/SMOG/SMOKEo FOGWITH RAIN

o PARKWAYo STATEo NONEOFTHEABOVE

TOTAL LANESCD®illCDm®@CDill®CD®@

o RAININGo SEVERECROSSWINDSo SLEET/HAILo SNOWINGo OTHER

COLLISIONTIME-Military

o STOP SIGNo WARNINGSIGNSo YIELD SIGNo OTHERo NONE

LAND USEo BUSINESSo INDUSTRIALo LIMITEDACCESSo PARKo PRIVATEPROPERTYo RESIDENTIAL

SCHOOL BUS RELATEDo RURAL I0 DIRECTLYo SCHOOL 0 INDIRECTLY

o NOTAPPLICABLE

LIGHT CONDITIONo DAWN 0 DARKNESS-HIGHWAY LIGHTED/OFFo DAYLIGHT 0 DARKNESS-HIGHWAY LIGHTED/ONo DUSK 0 DARKNESS-HIGHWAY NOT LIGHTED

FIRST AID AT SCENE(J)®

FIRST AID GIVEN BY INJURED REMOVED TO

E.M.S.AGENCY DJJJ-AND RUN #

E.M.S. AGENCY DJJJ-AND RUN#

E.M.S. AGENCY DJJJ -AND RUN#

EMS TIME AT HOSPITAL IEMS NOTIFIED TIME IEMS ARRIVED TIMEEMS NOTIFIED TIME IEMS ARRIVED TIME EMS TIME AT HOSPITALEMS TIME AT HOSPITAL IEMS NOTIFIED TIME IEMS ARRIVED TIME

o POLICECARo PRIVATEAMBULANCEo PRIVATEVEHICLEo OTHER

INJURED OR DECEASED REMOVED BYo FUNERALHOME/CORONER'SVEHICLEo HELICOPTER/OTHERAIR VEHICLE

o MUNICIPAUCO.EMERGENCYVEHICLEo POLICE AMBULANCE

DESCRIPTION OF COLLISION

I.D. NUMBERINVESTIGATOR

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