20160613 WitheeAgency Accident Number
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Reportable Accident On Emergency Amended GZGXX62
DOT Document Number Document Override Number
16061307474
16
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6
1
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7
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16061305
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06/13/2016
4 - Accident Date
1325
5 - Time of Accident (Military Time)
01
6 - Total Units
01
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County HAYWARD - 06, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
077
14 - On Hwy No.14 - On Street Name 14 - Bus/Frnt/Rmp
200 FT15 - Est. Distance WEST15 - Hwy. Dir
16 - Fr/At Hwy No.SLEEPY HOLLOW RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number 12 - Latitude 13 - Longitude
TRAFFIC SIGN POST80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - Manner of Collision
NO CONTROL
112 - Access Control
STRAIGHT
113 - Road Curvature
LEVEL/FLAT
113 - Road Terrain
BLACKTOP, BITUMINOUS, OR ASPHALT - 2
Surface Type
NOT-PHYSICALLY-DIVIDED-(2-WAY TRAFFIC)115 - Traffic Way
OUTSIDE-SHOULDER-LEFT
117 - Relation To Roadway
DAYLIGHT114 - Light Condition DRY116 - Road Surface Condition CLEAR118 - Weather
Hit and Run
9
Government Property
9
Fire
9
Photos Taken
9
Trailer or Towed
9
Truck, Bus, or Hazardous Materials
9
Load Spillage
9
Construction Zone
9
Names Exchanged
9
Supplemental Reports
101
Witness Statements
102
Measurements Taken
103
1606130747479 - E M S Number
Operator/Pedestrian
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Unit Status
TRAFFIC SIGN POST
81 - Most Harmful Event: Collision With
WEST
23 - Dir Of Travel
5524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
WI
30 - State
2019
31 - Expiration Year 34 - On Duty Accident
WITHEE
25 - Operator/Pedestrian Last Name
ORRIS
25 - First Name
W
25 - Middle Initial 25 - Suffix
08/01/
32 - Date Of Birth
MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
BRODHEAD
27 - City
WI
27 - State
53520
27 - Zip Code
.
28 - Telephone Number
FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR)
39 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-USED
40 - Safety Equipment
B - NON-INCAPACITATING INJURY
38 - Injury Severity
NON-DEPLOYED
41 - Airbag
NOT-EJECTED
42 - Ejected 44
Medical Transport
NOT-TRAPPED
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
GOING-STRAIGHT
119 - What Driver Was Doing
NO-CONTROL
120 - Traffic Control 062 - No. of Citations Issued
64 - 1st Statute No.64 - 2nd Statute No.64 - 3rd Statute No.64 - 4th Statute No.64 - 5th Statute No.
LEFT-OF-CENTER, FAILURE-TO-HAVE-CONTROL, DRIVER-CONDITION, PHYSICALLY-DISABLED
122 - Driver Factors
ABILITY IMPAIRED88 - Driver or Pedestrian Cond UNKNOWN
89 - Substance Presence
TEST NOT GIVEN90 - Alcohol Test 90 - Alcohol Content TEST NOT GIVEN91 - Drug Test
01
Accident Report
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Wisconsin Motor Vehicle GZGXX62 1 4
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
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91 - Drugs Reported
NOT-APPLICABLE
124 - Highway Factors
TRUCK
21 - Unit Type
PICKUP/UTILITY-TRUCK
Vehicle Type
2
22 - Total Occupants
DAV36
56 - License Plate Number
LTK57 - Plate Type WI
58 - State
2017
59 - Exp Year
9995
55 - Vehicle Identification Number
2014
50 - Year
FORD
51 - Make
F150
52 - Model
TK - TRUCK
53 - Body Style
MAR
54 - Color
0100 - Skidmarks to Impact (Ft)
FRONT, REAR PASSENGER SIDE, FRONT DRIVER SIDE
94 - Vehicle Damage
MODERATE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96 97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
WITHEE
46 - Vehicle Owner Last Name
ORRIS
46 - First Name
W
46 - Middle Initial 46 - Suffix
08/01
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
BRODHEAD48 - City WI48 - State 5352048 - Zip Code 49 - Telephone Number
AMERICAN-FAMILY63 - Liability Insurance Company Policy Holder Same As Owner60
WITHEE
61 - Policy Holder Last Name
ORRIS
61 - Policy Holder First Name
61 - Policy Holder Company
01
01
01
01
BU
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FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Occupant
Address Same As Operator
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65 - Unit No
WITHEE
66 - Occupant Last Name
ROSE
66 - First Name
M
66 - Middle Initial 66 - Suffix
01
Number 68 - PO Box
BRODHEAD
68 - City
WI
68 - State
53520
68 - Zip Code
12/09/67 - Date of Birth F69 - Sex
FRONT-SEAT-RIGHT-SIDE-(TRAIN ENGINEER)
71 - Seat Position
SHOULDER-BELT-AND-LAP-BELT-USED
72 - Safety Equipment
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZGXX62 2 424
N - NO APPARENT INJURY
70 - Injury Severity
NON-DEPLOYED
73 - Airbag
NOT-EJECTED
75 - Ejected
Medical Transport
77
NOT-TRAPPED
76 - Trapped/Extricated 78 - Agency Space
Trailer
01
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106 - Power Unit Number License Plate Number Plate Type State Expiration Year
Trailer Make Unit Type Vehicle Identification Number
Fixed Objects Struck
PR
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Property
GOVERNMENT
Organization Type 84 - Property Owner Last Name 84 - First Name 84 - Middle Initial 84 - Suffix
01
SAWYER COUNTY
84 - Company Name
COUNTY/MUNICIPAL
Government Property Type
14688W COUNTY HWY B
85 - Address Street & Number 85 - PO Box
HAYWARD
86 - City
WI
86 - State
54843
86 - Zip Code
(715) 634-4824 EXT.
87 - Telephone Number
83 - Government Damage Tag Number
01
82 - Striking Unit
TRAFFIC-SIGN-POST
82 - Object Struck 82 - Striking Unit 82 - Object Struck
82 - Striking Unit 82 - Object Struck 82 - Striking Unit 82 - Object Struck
82 - Striking Unit 82 - Object Struck 82 - Striking Unit 82 - Object Struck
105 - Photos By
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Diagram and Narrative
POPLIN
ON JUNE 13TH, 2016 I DEPUTY POPLIN WAS DISPATCHED TO A TRAFFIC CRASH ON STATE HWY 77. UPON ARRIVAL I SAW THAT
UNIT 1 WAS WESTBOUND ON STATE HWY 77. I OBSERVED THAT UNIT 1 LEFT THE ROADWAY JUST WEST OF THE INTERSECTION OF
SLEEPY HOLLOW RD AND TRAVELED THROUGH THE DITCH FOR APPROXIMATELY 1/4 MILE GOING OVER SEVERAL DRIVEWAY INTERSECTIONS. UNIT 1 ALSO STRUCK A TRAFFIC SIGN SNAPPING THE POST AND
ON JUNE 13TH, 2016 I DEPUTY POPLIN WAS DISPATCHED TO A TRAFFIC CRASH ON STATE HWY 77. UPON ARRIVAL I SAW THAT
UNIT 1 WAS WESTBOUND ON STATE HWY 77. I OBSERVED THAT UNIT 1 LEFT THE ROADWAY JUST WEST OF THE INTERSECTION OF
SLEEPY HOLLOW RD AND TRAVELED THROUGH THE DITCH FOR APPROXIMATELY 1/4 MILE GOING OVER SEVERAL DRIVEWAY INTERSECTIONS. UNIT 1 ALSO STRUCK A TRAFFIC SIGN SNAPPING THE POST AND
Accident Report
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Wisconsin Motor Vehicle GZGXX62 3 4
CONTINUED THROUGH THE DITCH FURTHER. TWO WITNESSES ADVISED THEY WERE RUN OFF OF THE ROADWAY BY UNIT 1 AND WROTE WRITTEN STATEMENTS. UPON CONTACT WITH THE DRIVER OF UNIT 1 HE WAS VERY ELDERLY AND ALSO SAID HE WAS
HARD OF HEARING. HE TOLD ME HE HIT GRAVEL AND THIS CAUSED HIM TO CROSS THE ENTIRE ROADWAY AND GO INTO THE
DITCH. ONCE IN THE DITCH HE TRAVELED A VERY LONG WAYS WITHOUT TRYING TO COME BACK ONTO THE ROAD OR STOP. THE
DRIVER'S PHYSICAL ABILITY APPEARED TO BE AFFECTED BY HIS AGE AND ALSO HE STATED HE HAD PHYSICAL ISSUES WITH IS
BACK. A DRIVER CONDITION REPORT WILL ALSO BE COMPLETED WITH THIS MATTER.
CONTINUED THROUGH THE DITCH FURTHER. TWO WITNESSES ADVISED THEY WERE RUN OFF OF THE ROADWAY BY UNIT 1 AND WROTE WRITTEN STATEMENTS. UPON CONTACT WITH THE DRIVER OF UNIT 1 HE WAS VERY ELDERLY AND ALSO SAID HE WAS
HARD OF HEARING. HE TOLD ME HE HIT GRAVEL AND THIS CAUSED HIM TO CROSS THE ENTIRE ROADWAY AND GO INTO THE
DITCH. ONCE IN THE DITCH HE TRAVELED A VERY LONG WAYS WITHOUT TRYING TO COME BACK ONTO THE ROAD OR STOP. THE
DRIVER'S PHYSICAL ABILITY APPEARED TO BE AFFECTED BY HIS AGE AND ALSO HE STATED HE HAD PHYSICAL ISSUES WITH IS
BACK. A DRIVER CONDITION REPORT WILL ALSO BE COMPLETED WITH THIS MATTER.
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125 - First Name 125 - Middle Initial
Officer Information
POPLIN
125 - Officer Last Name
JAY 352
131 - Officer ID
129 - Law Enforcement Agency No.SAWYER COUNTY SHERIFFS DEPT130 - Law Enforcement Agency Name
15880 EAST FIFTH STREET
126 - Law Enforcement Agency Address Street & Number
HAYWARD127 - City WI127 - State 54843127 - Zip Code (715) 634-4858 EXT.128 - Telephone Number
06/13/2016
132 - Date Notified 1325133 - Time Notified (Military Time)1329134 - Time Arrived (Military Time)
06/14/2016
135 - Date Of Report
16061307474 16061305 19 - Special Study
18 - Agency Space
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZGXX62 4 4