20161204 NeasAgency Accident Number
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Reportable Accident On Emergency Amended GZHL5ZC
DOT Document Number Document Override Number
16120416147
16
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0
4
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6
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16120404
16
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12/04/2016
4 - Accident Date
1452
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
14 - On Hwy No.
WHEELER RD
14 - On Street Name 14 - Bus/Frnt/Rmp
537 FT15 - Est. Distance SOUTH15 - Hwy. Dir
07716 - Fr/At Hwy No.16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.009779
12 - Latitude -91.44669313 - Longitude
OVERTURN80 - 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-RIGHT
117 - Relation To Roadway
DAYLIGHT114 - Light Condition SNOW/SLUSH116 - Road Surface Condition SNOW118 - 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
1612041614779 - E M S Number
Operator/Pedestrian
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Unit Status
DITCH
81 - Most Harmful Event: Collision With
SOUTH
23 - Dir Of Travel
2524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
WI
30 - State
2021
31 - Expiration Year 34 - On Duty Accident
NEAS
25 - Operator/Pedestrian Last Name
ANGELA
25 - First Name
ROSE
25 - Middle Initial 25 - Suffix
07/12/
32 - Date Of Birth
FEMALE
33 - Sex
26 - Address Street & Number 26 - PO Box
HAYWARD
27 - City
WI
27 - State
54843
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
N - NO APPARENT INJURY
38 - Injury Severity
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.
NOT-APPLICABLE
122 - Driver Factors
APPEARED NORMAL88 - Driver or Pedestrian Cond NEITHER-ALCOHOL-NOR-DRUGS-PRESENT
89 - Substance Presence
TEST NOT GIVEN90 - Alcohol Test 90 - Alcohol Content TEST NOT GIVEN91 - Drug Test
01
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZHL5ZC 1 4
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Vehicle
Vehicle Owner
Insurance
School Bus
IN
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91 - Drugs Reported
SNOW,-ICE,-OR-WET
124 - Highway Factors
TRUCK
21 - Unit Type
PICKUP/UTILITY-TRUCK
Vehicle Type
2
22 - Total Occupants
MN1654
56 - License Plate Number
LTK57 - Plate Type WI
58 - State
2017
59 - Exp Year
54341
55 - Vehicle Identification Number
2002
50 - Year
DODG
51 - Make
DAKOTA
52 - Model
PK - PICKUP
53 - Body Style
SIL
54 - Color 100 - Skidmarks to Impact (Ft)
MIDDLE PASSENGER SIDE, TOP OF VEHICLE, FRONT DRIVER SIDE, FRONT
94 - Vehicle Damage
SEVERE
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
NEAS
46 - Vehicle Owner Last Name
ANGELA
46 - First Name
ROSE
46 - Middle Initial 46 - Suffix
07/12
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
UNKNOWN63 - Liability Insurance Company Policy Holder Same As Owner60
61 - Policy Holder Last Name 61 - Policy Holder First Name
61 - Policy Holder Company
01
01
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FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Occupant
Address Same As Operator
OC
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65 - Unit No
NEAS
66 - Occupant Last Name
WALTER
66 - First Name
S
66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
HAYWARD
68 - City
WI
68 - State
54843
68 - Zip Code
09/26/67 - Date of Birth M69 - Sex
FRONT-SEAT-RIGHT-SIDE-(TRAIN ENGINEER)
71 - Seat Position
NONE-USED-VEHICLE-DRIVER/OCCUPANT
72 - Safety Equipment
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZHL5ZC 2 424
C - POSSIBLE INJURY
70 - Injury Severity
DEPLOYED
73 - Airbag
NOT-EJECTED
75 - Ejected
Medical Transport
77
TRAPPED/EXTRICATED
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
Organization Type 84 - Property Owner Last Name 84 - First Name 84 - Middle Initial 84 - Suffix
01
84 - Company Name Government Property Type
85 - Address Street & Number 85 - PO Box
86 - City 86 - State 86 - Zip Code 87 - Telephone Number
83 - Government Damage Tag Number
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 82 - Striking Unit 82 - Object Struck
105 - Photos By
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Diagram and Narrative
HOUSE/317
UNIT 1 WAS TRAVELLING SOUTH ON WHEELER ROAD OFF OF HIGHWAY 77..AS IT ACCELERATED ON WHEELER ROAD, UNIT 1 LOST
CONTROL AND WENT INTO DITCH AND OVER TURNED. UNIT 1 PASSENGER WAS TRAPPED AND HAD TO BE EXTRICATED. MINOR
INJURIES REPORTED AND WAS TRANSPORTED TO HAYWARD HOSPITAL..VEHICLE HAD SEVERE DAMAGE. SNOW AND ICE COVERED ROADS WERE A FACTOR IN REGARDS TO THIS INCIDENT.
UNIT 1 WAS TRAVELLING SOUTH ON WHEELER ROAD OFF OF HIGHWAY 77..AS IT ACCELERATED ON WHEELER ROAD, UNIT 1 LOST
CONTROL AND WENT INTO DITCH AND OVER TURNED. UNIT 1 PASSENGER WAS TRAPPED AND HAD TO BE EXTRICATED. MINOR
INJURIES REPORTED AND WAS TRANSPORTED TO HAYWARD HOSPITAL..VEHICLE HAD SEVERE DAMAGE. SNOW AND ICE COVERED ROADS WERE A FACTOR IN REGARDS TO THIS INCIDENT.
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZHL5ZC 3 4
OF
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125 - First Name 125 - Middle Initial
Officer Information
HOUSE
125 - Officer Last Name
ROB 317
131 - Officer ID
129 - Law Enforcement Agency No.
SAWYER COUNTY SHERIFFS DEPT
130 - Law Enforcement Agency Name
15880 EAST FIFTH STREET
126 - Law Enforcement Agency Address Street & Number
HAYWARD
127 - City
WI
127 - State
54843
127 - Zip Code
(715) 634-4858 EXT.
128 - Telephone Number
12/04/2016
132 - Date Notified 1452133 - Time Notified (Military Time)1454134 - Time Arrived (Military Time)
12/11/2016
135 - Date Of Report
16120416147 16120404 19 - Special Study
18 - Agency Space
136
136
136 136
136
Truck and Bus
A truck or truck combination > 10,000 lbs
GVWR/GCWR
Any vehicle displaying a hazardous materials
placard
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A vehicle designed to carry 9 or more people, including the driver
136
Fatal Injury Medical Transport
One or more vehicles towed from the scene due to disabling damage
01Unit Number
137 - Hazardous Materials Class Numbers
137 - Hazardous Materials "UN" Nos.HazMat Placard Displayed Hazardous Cargo Was Released
137 - Name Of Hazardous Materials in this Load 137 - Name Of Hazardous Materials Released
Interstate Carrier138 140 - US DOT No.140 - ICC MC No.LC No.IC No.DRIVER141 - Source
NEAS
139 - Carrier Name
HAYWARD
142 - Carrier Address City State Zip Code
143 - GVWR (Lbs)144 - Total No. of Axles
SINGLE-UNIT-VEHICLE
145 - Vehicle Configuration
AUTO-TRANSPORTER
147 - Cargo Body Type
BLANK146 - First Event BLANK146 - Second Event
BLANK
146 - Third Event
BLANK
146 - Fourth Event
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZHL5ZC 4 4