HomeMy WebLinkAbout20151019 RiveraAgency Accident Number
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Reportable Accident On Emergency Amended GZDWFQZ
DOT Document Number Document Override Number
15101902
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15101902
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10/19/2015
4 - Accident Date
0736
5 - Time of Accident (Military Time)
01
6 - Total Units
02
7 - Total Injured 8 - Total Killed
SAWYER - 572 - County WEIRGOR - 16, TOWN3 - Municipality INTERSECTION11 - Accident Location
14 - On Hwy No.
REPPERT RD
14 - On Street Name 14 - Bus/Frnt/Rmp 15 - Est. Distance 15 - Hwy. Dir
16 - Fr/At Hwy No.GORDON RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.711243
12 - Latitude -91.19420913 - Longitude
EMBANKMENT80 - 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 79 - E M S Number
Operator/Pedestrian
OP
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Unit Status
EMBANKMENT
81 - Most Harmful Event: Collision With
SOUTH
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 31 - Expiration Year 34 - On Duty Accident
RIVERA
25 - Operator/Pedestrian Last Name
SERGHIO
25 - First Name
ALEXIS
25 - Middle Initial 25 - Suffix
08/29/MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
EXELAND
27 - City
WI
27 - State
54835
27 - Zip Code 28 - Telephone Number
FRONT-SEAT-LEFT-SIDE-(MC/BIKE DRIVER, TRAIN CONDUCTOR)
39 - Seat Position
RESTRAINT-USE-UNKNOWN
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 262 - No. of Citations Issued
346.63(2)(A)1
64 - 1st Statute No.
343.05(3)(A)
64 - 2nd Statute No.64 - 3rd Statute No.64 - 4th Statute No.64 - 5th Statute No.
DRIVER-CONDITION
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
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFQZ 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
AUTOMOBILE
21 - Unit Type
PASSENGER-CAR
Vehicle Type
2
22 - Total Occupants
393VJV
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
7348
55 - Vehicle Identification Number
2006
50 - Year
CHEV
51 - Make
AVEO
52 - Model
4D - 4DR
53 - Body Style
SIL
54 - Color
60100 - Skidmarks to Impact (Ft)
FRONT
94 - Vehicle Damage
MINOR
95 - Extent Of Damage
Vehicle Towed Due To Damage
96
A-1 TOWING
97 - Vehicle Removed By
NOT-APPLICABLE
123 - Vehicle Factors
45
Vehicle Owner Same As Operator
JAPON
46 - Vehicle Owner Last Name
ABEL
46 - First Name
D
46 - Middle Initial 46 - Suffix
07/06/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
BALDWIN48 - City WI48 - State 5400248 - 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
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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01
65 - Unit No
SALAS
66 - Occupant Last Name
VALENTIN
66 - First Name
SANCHEZ
66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
EXELAND
68 - City
WI
68 - State
54835
68 - Zip Code
04/3067 - Date of Birth M69 - Sex
FRONT-SEAT-RIGHT-SIDE-(TRAIN ENGINEER)
71 - Seat Position
RESTRAINT-USE-UNKNOWN
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 GZDWFQZ 2 424
B - NON-INCAPACITATING 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
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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
EMBANKMENT
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
UNIT ONE WAS SOUTHBOUND ON REPPERT RD WHEN IT LET THE ROADWAY ON THE EAST SIDE, TRAVELED 78 FEET TO A
DRIVEWAY THEN ANOTHER 114 FEET STILL IN THE EAST DITCH TO THE INTERSECTION OF GORDON ROAD, CROSSED GORDON
ROAD AND STRUCK A SMALL EMBANKMENT CAUSING DAMAGE TO THE VEHICLE. IT STOPPED 10 FEET BEYOND THE EMBANKMENT STILL HEADED SOUTH.
UNIT ONE WAS SOUTHBOUND ON REPPERT RD WHEN IT LET THE ROADWAY ON THE EAST SIDE, TRAVELED 78 FEET TO A
DRIVEWAY THEN ANOTHER 114 FEET STILL IN THE EAST DITCH TO THE INTERSECTION OF GORDON ROAD, CROSSED GORDON
ROAD AND STRUCK A SMALL EMBANKMENT CAUSING DAMAGE TO THE VEHICLE. IT STOPPED 10 FEET BEYOND THE EMBANKMENT STILL HEADED SOUTH.
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFQZ 3 4
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125 - First Name 125 - Middle Initial
Officer Information
CAIN
125 - Officer Last Name
JEFF 314
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
10/19/2015
132 - Date Notified 0736133 - Time Notified (Military Time)0755134 - Time Arrived (Military Time)
10/20/2015
135 - Date Of Report
15101902 15101902 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDWFQZ 4 4