20161206 MarksAgency Accident Number
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Reportable Accident On Emergency Amended GZJ2866
DOT Document Number Document Override Number
16120616200
16
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6
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16120603
16
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6
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12/06/2016
4 - Accident Date
0700
5 - Time of Accident (Military Time)
01
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County HAYWARD - 06, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
14 - On Hwy No.
ROUND LAKE SCHOOL RD
14 - On Street Name 14 - Bus/Frnt/Rmp
0.50 MI15 - Est. Distance NORTH15 - Hwy. Dir
16 - Fr/At Hwy No.PENINSULA RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
46.018937
12 - Latitude -91.36309613 - Longitude
OTHER 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
ON-ROADWAY
117 - Relation To Roadway
DAYLIGHT114 - Light Condition ICE116 - 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 79 - E M S Number
Operator/Pedestrian
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Unit Status
OTHER POST
81 - Most Harmful Event: Collision With
NORTH
23 - Dir Of Travel
4524 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
WI
30 - State
2018
31 - Expiration Year 34 - On Duty Accident
MARKS
25 - Operator/Pedestrian Last Name
CHARLES
25 - First Name
J
25 - Middle Initial 25 - Suffix
06/09/1
32 - Date Of Birth
MALE
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
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 62 - No. of Citations Issued
64 - 1st Statute No.64 - 2nd Statute No.64 - 3rd Statute No.64 - 4th Statute No.64 - 5th Statute No.
SPEED-TOO-FAST-FOR-CONDITIONS
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
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZJ2866 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
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
1
22 - Total Occupants
819SMY
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2017
59 - Exp Year
66
55 - Vehicle Identification Number
2002
50 - Year
DODG
51 - Make
CARAVAN
52 - Model
VN - VAN
53 - Body Style
BRO
54 - Color 100 - Skidmarks to Impact (Ft)
REAR DRIVER SIDE, MIDDLE DRIVER SIDE
94 - Vehicle Damage
SEVERE
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
OWNER
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
MARKS
46 - Vehicle Owner Last Name
CHARLES
46 - First Name
J
46 - Middle Initial 46 - Suffix
06/09
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
HAYWARD48 - City WI48 - State 5484348 - Zip Code 49 - Telephone Number
AMERICAN-FAMILY63 - Liability Insurance Company Policy Holder Same As Owner60
MARKS
61 - Policy Holder Last Name
CHARLES
61 - Policy Holder First Name
61 - Policy Holder Company
01
01
01
01
BU
S
FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Trailer
01
TR
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106 - Power Unit Number License Plate Number Plate Type State Expiration Year
Trailer Make Unit Type Vehicle Identification Number
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Wisconsin Motor Vehicle GZJ2866 2 424
Fixed Objects Struck
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Property
UNKNOWN
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
01
82 - Striking Unit
OTHER-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
DEPUTY AMBER AL-MOGHRABI
ON DECEMBER 6, 2016 AT APPROXIMATELY 7:14, I WAS DISPATCHED TO ROUND LAKE SCHOOL ROAD JUST SOUTH OF STATE HWY
77 FOR A REPORT OF A ONE VEHICLE ACCIDENT. UPON ARRIVAL AT 7:28 I NOTICED THE DRIVER SIDE OF THE BROWN VAN HAD
HIT A UTILITY POLE AND WAS STUCK IN SOME BARBED WIRE. THE DRIVER OF THE VEHICLE STEPPED OUT AND INTRODUCED
HIMSELF AS CHARLES MARKS. HE STATED HE WAS TRAVELING NORTHBOUND ON ROUND LAKE SCHOOL ROAD TOWARDS STATE
HWY 77 WHEN HE LOST CONTROL OF HIS VEHICLE AND SLID INTO THE WESTBOUND LANE AND INTO THE DITCH. CHARLES
STATED HE WAS TRAVELING APPROXIMATELY 40 TO 45 MILES PER HOUR AND THAT HE WAS WEARING HIS SEAT BELT. CHARLES ALSO STATED THAT HE HAD NOT BEEN DRINKING OR ON DRUGS AND THAT HE WAS ON HIS WAY TO WORK. I NOTICED THERE
WAS SEVERE DAMAGE TO THE DRIVER SIDE OF HIS VEHICLE. THE VAN WAS DENTED FROM THE DRIVER DOOR TO THE TAILLIGHT
AND THE REAR DRIVER SIDE WINDOW HAD SHATTERED AND WAS MISSING. I TOOK PICTURES OF THE VEHICLE AND INFORMED
CHARLES TO GET AN ESTIMATE OF THE DAMAGE AND CALL HIS INSURANCE COMPANY. A-1 TOWED THE VEHICLE OUT OF THE
DITCH, BUT CHARLES WAS ABLE TO DRIVE IT HOME. I CLEARED THE CALL AT 8:27 AND ENTERED THE PICTURES INTO EVIDENCE.
THIS IS ALL THE INFORMATION I HAVE AT THIS TIME.
ON DECEMBER 6, 2016 AT APPROXIMATELY 7:14, I WAS DISPATCHED TO ROUND LAKE SCHOOL ROAD JUST SOUTH OF STATE HWY
77 FOR A REPORT OF A ONE VEHICLE ACCIDENT. UPON ARRIVAL AT 7:28 I NOTICED THE DRIVER SIDE OF THE BROWN VAN HAD
HIT A UTILITY POLE AND WAS STUCK IN SOME BARBED WIRE. THE DRIVER OF THE VEHICLE STEPPED OUT AND INTRODUCED
HIMSELF AS CHARLES MARKS. HE STATED HE WAS TRAVELING NORTHBOUND ON ROUND LAKE SCHOOL ROAD TOWARDS STATE
HWY 77 WHEN HE LOST CONTROL OF HIS VEHICLE AND SLID INTO THE WESTBOUND LANE AND INTO THE DITCH. CHARLES
STATED HE WAS TRAVELING APPROXIMATELY 40 TO 45 MILES PER HOUR AND THAT HE WAS WEARING HIS SEAT BELT. CHARLES ALSO STATED THAT HE HAD NOT BEEN DRINKING OR ON DRUGS AND THAT HE WAS ON HIS WAY TO WORK. I NOTICED THERE
WAS SEVERE DAMAGE TO THE DRIVER SIDE OF HIS VEHICLE. THE VAN WAS DENTED FROM THE DRIVER DOOR TO THE TAILLIGHT
AND THE REAR DRIVER SIDE WINDOW HAD SHATTERED AND WAS MISSING. I TOOK PICTURES OF THE VEHICLE AND INFORMED
CHARLES TO GET AN ESTIMATE OF THE DAMAGE AND CALL HIS INSURANCE COMPANY. A-1 TOWED THE VEHICLE OUT OF THE
DITCH, BUT CHARLES WAS ABLE TO DRIVE IT HOME. I CLEARED THE CALL AT 8:27 AND ENTERED THE PICTURES INTO EVIDENCE.
THIS IS ALL THE INFORMATION I HAVE AT THIS TIME.
Officer Information
Accident Report
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZJ2866 3 4
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125 - First Name 125 - Middle Initial
ALMOGHRABI
125 - Officer Last Name
AMBER 340
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
12/06/2016
132 - Date Notified 0714133 - Time Notified (Military Time)0728134 - Time Arrived (Military Time)
12/06/2016
135 - Date Of Report
16120616200 16120603 19 - Special Study
18 - Agency Space
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MV4000e 01/2005
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Wisconsin Motor Vehicle GZJ2866 4 4