HomeMy WebLinkAbout20151113 HabermanAgency Accident Number
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Reportable Accident On Emergency Amended GZDC4V5
DOT Document Number Document Override Number
11/13/2015
4 - Accident Date
1025
5 - Time of Accident (Military Time)
01
6 - Total Units
01
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County HUNTER - 07, TOWN3 - Municipality NON-INTERSECTION11 - Accident Location
B
14 - On Hwy No.14 - On Street Name 14 - Bus/Frnt/Rmp
927 FT15 - Est. Distance SOUTH15 - Hwy. Dir
16 - Fr/At Hwy No.RIVER RD16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.964767
12 - Latitude -91.12501813 - Longitude
TREE80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - Manner of Collision
NO CONTROL
112 - Access Control
CURVE
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
TREE
81 - Most Harmful Event: Collision With
EAST
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
2023
31 - Expiration Year 34 - On Duty Accident
HABERMAN
25 - Operator/Pedestrian Last Name
SCOTT
25 - First Name
W
25 - Middle Initial 25 - Suffix
06/09/MALE
33 - Sex
26 - Address Street & Number 26 - PO Box
LAKE MILLS
27 - City
WI
27 - State
53551
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
NEGOTIATING-CURVE
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.
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 GZDC4V5 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
2
22 - Total Occupants
557SSC
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
1005
55 - Vehicle Identification Number
2011
50 - Year
HYUN
51 - Make
ELANTRA
52 - Model
4D - 4DR
53 - Body Style
BLU
54 - Color 100 - Skidmarks to Impact (Ft)
FRONT, FRONT DRIVER SIDE, FRONT PASSENGER SIDE
94 - Vehicle Damage
VERY-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
HABERMAN
46 - Vehicle Owner Last Name
SCOTT
46 - First Name
W
46 - Middle Initial 46 - Suffix
06/09/
Date Of Birth
46 - Company Name
47- Address Street & Number 47 - PO Box
LAKE MILLS48 - City WI48 - State 5355148 - Zip Code 49 - Telephone Number
UNKNOWN63 - Liability Insurance Company Policy Holder Same As Owner60
HABERMANN
61 - Policy Holder Last Name
SCOTT
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
HABERMANN
66 - Occupant Last Name
KELLY
66 - First Name
M
66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
LAKE MILLS
68 - City
WI
68 - State
53551
68 - Zip Code
05/2967 - 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
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDC4V5 2 424
C - POSSIBLE INJURY
70 - Injury Severity
DEPLOYED
73 - Airbag
NOT-APPLICABLE
75 - Ejected
Medical Transport
77
NOT-APPLICABLE
76 - Trapped/Extricated
38S SQUAD A SHIFT
78 - Agency Space
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
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
TREE
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
ON 11-13-15 AT 1025 DEPUTY NELSON WAS DISPATCHED TO CTH B EAST OF CTH S FOR A ONE CAR VEHICLE ACCIDENT. DEPUTY
NELSON ARRIVED ON SCENE AT 1048. DEPUTY FOUND THAT THE VEHICLE WAS TRAVELING EAST BOND ON CTH B EAST OF RIVER
RD. THE OPERATOR OF THE VEHICLE ADVISED THAT WHEN HE WENT OVER THE BRIDGE HE LOST CONTROL OF THE VEHICLE. DEPUTY NELSON NOTED THAT THE BRIDGE WAS COVERED IN SLUSH AND ICE AT THE TIME
ON 11-13-15 AT 1025 DEPUTY NELSON WAS DISPATCHED TO CTH B EAST OF CTH S FOR A ONE CAR VEHICLE ACCIDENT. DEPUTY
NELSON ARRIVED ON SCENE AT 1048. DEPUTY FOUND THAT THE VEHICLE WAS TRAVELING EAST BOND ON CTH B EAST OF RIVER
RD. THE OPERATOR OF THE VEHICLE ADVISED THAT WHEN HE WENT OVER THE BRIDGE HE LOST CONTROL OF THE VEHICLE. DEPUTY NELSON NOTED THAT THE BRIDGE WAS COVERED IN SLUSH AND ICE AT THE TIME
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDC4V5 3 4
OF THE ACCIDENT. THE PASSENGER OF THE VEHICLE WAS TRANSPORTED TO HAMH FOR MINOR INJURIES.OF THE ACCIDENT. THE PASSENGER OF THE VEHICLE WAS TRANSPORTED TO HAMH FOR MINOR INJURIES.
OF
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125 - First Name 125 - Middle Initial
Officer Information
NELSON
125 - Officer Last Name
DENNIS 382
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
11/22/2015
132 - Date Notified 1025133 - Time Notified (Military Time)1048134 - Time Arrived (Military Time)
11/22/2015
135 - Date Of Report
19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDC4V5 4 4