HomeMy WebLinkAbout20150112 Wampole Vana AmendedAgency Accident Number
AC
C
I
D
E
N
T
#
PO
L
I
C
E
#
Police Number
GE
N
E
R
A
L
I
N
F
O
R
M
A
T
I
O
N
Reportable Accident On Emergency Amended GZDT72Q
DOT Document Number
GZ114XC
Document Override Number
15011201
15
0
1
1
2
0
1
15011201
15
0
1
1
2
0
1
01/12/2015
4 - Accident Date
1230
5 - Time of Accident (Military Time)
02
6 - Total Units
00
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County LENROOT - 08, TOWN3 - Municipality 11 - Accident Location
14 - On Hwy No.14 - On Street Name 14 - Bus/Frnt/Rmp 15 - Est. Distance 15 - Hwy. Dir
16 - Fr/At Hwy No.16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number 12 - Latitude 13 - Longitude
80 - First Harmful Event 93 - Manner of Collision
112 - Access Control 113 - Road Curvature 113 - Road Terrain Surface Type
115 - Traffic Way
117 - Relation To Roadway
114 - Light Condition 116 - Road Surface Condition 118 - 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
OP
E
R
A
T
O
R
/
P
E
D
E
S
T
R
I
A
N
Unit Status 81 - Most Harmful Event: Collision With 23 - Dir Of Travel 24 - Speed Limit
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number 30 - State 31 - Expiration Year 34 - On Duty Accident
WAMPOLE
25 - Operator/Pedestrian Last Name
SHANE
25 - First Name
M
25 - Middle Initial 25 - Suffix
32 - Date Of Birth 33 - Sex
26 - Address Street & Number 26 - PO Box
27 - City 27 - State 27 - Zip Code 28 - Telephone Number
39 - Seat Position 40 - Safety Equipment
38 - Injury Severity 41 - Airbag 42 - Ejected 44
Medical Transport
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
119 - What Driver Was Doing 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.
122 - Driver Factors
88 - Driver or Pedestrian Cond 89 - Substance Presence
90 - Alcohol Test 90 - Alcohol Content 91 - Drug Test
01
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDT72Q 1 4
VE
H
I
C
L
E
VE
H
O
W
N
E
R
Vehicle
Vehicle Owner
Insurance
School Bus
IN
S
91 - Drugs Reported
124 - Highway Factors
21 - Unit Type Vehicle Type 22 - Total Occupants
56 - License Plate Number 57 - Plate Type 58 - State 59 - Exp Year 55 - Vehicle Identification Number
50 - Year 51 - Make 52 - Model 53 - Body Style 54 - Color 100 - Skidmarks to Impact (Ft)
94 - Vehicle Damage
95 - Extent Of Damage
Vehicle Towed Due To Damage
96 97 - Vehicle Removed By
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
WAMPOLE
46 - Vehicle Owner Last Name
SHANE
46 - First Name
M
46 - Middle Initial 46 - Suffix Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
48 - City 48 - State 48 - Zip Code 49 - Telephone Number
63 - Liability Insurance Company Policy Holder Same As Owner60
61 - Policy Holder Last Name 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
Operator/Pedestrian
Unit Status 81 - Most Harmful Event: Collision With 23 - Dir Of Travel 24 - Speed Limit
D CLASS
36 - Operating as Classified 37 - Endorsements 35
Operating Commercial Motor Vehicle
29 - Driver's License Number
WI
30 - State
2014
31 - Expiration Year 34 - On Duty Accident
VANA
25 - Operator/Pedestrian Last Name
ROBERT
25 - First Name
J
25 - Middle Initial 25 - Suffix
07/11/
32 - Date Of Birth
MALE
33 - Sex
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDT72Q 2 424
VE
H
I
C
L
E
VE
H
O
W
N
E
R
Vehicle
Vehicle Owner
Insurance
OP
E
R
A
T
O
R
/
P
E
D
E
S
T
R
I
A
N
IN
S
11700 N MOSQUITO BROOK ROAD
26 - Address Street & Number 26 - PO Box
HAYWARD
27 - City
WI
27 - State
54843
27 - Zip Code 28 - Telephone Number
39 - Seat Position 40 - Safety Equipment
38 - Injury Severity 41 - Airbag 42 - Ejected 44
Medical Transport
43 - Trapped/Extricated 92 - Pedestrian Location 92 - Pedestrian Action
119 - What Driver Was Doing 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.
122 - Driver Factors
88 - Driver or Pedestrian Cond 89 - Substance Presence
90 - Alcohol Test 90 - Alcohol Content 91 - Drug Test
91 - Drugs Reported
124 - Highway Factors
21 - Unit Type Vehicle Type 22 - Total Occupants
56 - License Plate Number 57 - Plate Type 58 - State 59 - Exp Year 55 - Vehicle Identification Number
50 - Year 51 - Make 52 - Model 53 - Body Style 54 - Color 100 - Skidmarks to Impact (Ft)
94 - Vehicle Damage
95 - Extent Of Damage
Vehicle Towed Due To Damage
96 97 - Vehicle Removed By
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
NIVER
46 - Vehicle Owner Last Name
ROBIN
46 - First Name
C
46 - Middle Initial 46 - Suffix
07/07/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
48 - City 48 - State 48 - Zip Code 49 - Telephone Number
63 - Liability Insurance Company Policy Holder Same As Owner60
61 - Policy Holder Last Name 61 - Policy Holder First Name
61 - Policy Holder Company
02
02
02
02
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDT72Q 3 4
School Bus
02
BU
S
FromTo
Bus Travelling to/from School Name Body Make Seating Capacity
School District Contracted With
Trailer
01
TR
L
106 - Power Unit Number License Plate Number Plate Type State Expiration Year
Trailer Make Unit Type Vehicle Identification Number
105 - Photos By
DI
A
G
R
A
M
A
N
D
N
A
R
R
A
T
I
V
E
Diagram and Narrative
AMENDED CRASH REPORT TO AN INCIDENT ON JANUARY 12, 2015AMENDED CRASH REPORT TO AN INCIDENT ON JANUARY 12, 2015
OF
F
I
C
E
R
I
N
F
O
R
M
A
T
I
O
N
125 - First Name 125 - Middle Initial
Officer Information
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
01/12/2015
132 - Date Notified 1248133 - Time Notified (Military Time)1248134 - Time Arrived (Military Time)
01/12/2015
135 - Date Of Report
15011201 15011201 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDT72Q 4 4