HomeMy WebLinkAbout20160115 BrodskyAgency Accident Number
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Reportable Accident On Emergency Amended GZDTZ9L
DOT Document Number Document Override Number
16011501
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16011501
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01/15/2016
4 - Accident Date
0934
5 - Time of Accident (Military Time)
01
6 - Total Units
02
7 - Total Injured
00
8 - Total Killed
SAWYER - 572 - County HUNTER - 07, TOWN3 - Municipality INTERSECTION11 - Accident Location
CC
14 - On Hwy No.14 - On Street Name 14 - Bus/Frnt/Rmp 15 - Est. Distance 15 - Hwy. Dir
16 - Fr/At Hwy No.WOODLAND DR16 - From/At Street Name 16 - Business/Frontage/Ramp
17 - Structure Type 17 - Structure Number
45.922448
12 - Latitude -91.18836213 - Longitude
OTHER NON-COLLISION80 - First Harmful Event NO COLLISION WITH MOTOR VEHICLE IN TRANSPORT93 - Manner of Collision
NO CONTROL
112 - Access Control
CURVE
113 - Road Curvature
HILL
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 ICE116 - Road Surface Condition CLOUDY118 - 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
1601150059079 - E M S Number
Operator/Pedestrian
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Unit Status
TREE
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
2022
31 - Expiration Year 34 - On Duty Accident
BRODSKY
25 - Operator/Pedestrian Last Name
GERALD
25 - First Name
RAYMOND
25 - Middle Initial 25 - Suffix
01/27/
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
C - POSSIBLE 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
TRAFFIC-CONTROL-PERSON
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 GZDTZ9L 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
971NWE
56 - License Plate Number
AUT57 - Plate Type WI
58 - State
2016
59 - Exp Year
7768
55 - Vehicle Identification Number
2015
50 - Year
SUBA
51 - Make
FORESTER
52 - Model
2D - 2DR
53 - Body Style
BLK
54 - Color
0100 - Skidmarks to Impact (Ft)
FRONT, FRONT PASSENGER SIDE, FRONT DRIVER SIDE
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
BRODSKY
46 - Vehicle Owner Last Name
GERALD
46 - First Name
RAYMOND
46 - Middle Initial 46 - Suffix
01/27/1
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
BRODSKY
61 - Policy Holder Last Name
GEORGE
61 - Policy Holder First Name
61 - Policy Holder Company
01
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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
BRODSKY
66 - Occupant Last Name
JUDITH
66 - First Name
ELLEN
66 - Middle Initial 66 - Suffix
01
68 - Address Street & Number 68 - PO Box
HAYWARD
68 - City
WI
68 - State
54843
68 - Zip Code
11/03/67 - 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 GZDTZ9L 2 424
C - POSSIBLE INJURY
70 - Injury Severity
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
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
HAYWARD
86 - City
WI
86 - State
54843
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
DEPUTY HOSE
UNIT 1 WAS TRAVELING SOUTH ON WOODLAND DRIVE..WHILE NEGOTIATING A CURVE, UNIT 1 APPLIED BRAKES ON ICE COVERED
ROADWAY. UNIT 1 PROCEEDED INTO DITCH AND STRUCK A TREE. UNIT 1 SUSTAINED MAJOR DAMAGE TO FRONT END. BOTH
DRIVER AND PASSENGER WERE TRANSPORTED TO HOSPITAL FOR MINOR INJURIES. VEHICLE WAS TOWED DUE TO DAMAGE. ICE COVERED ROADS AND WEATHER CONDITIONS WERE A FACTOR IN THIS INCIDENT.
UNIT 1 WAS TRAVELING SOUTH ON WOODLAND DRIVE..WHILE NEGOTIATING A CURVE, UNIT 1 APPLIED BRAKES ON ICE COVERED
ROADWAY. UNIT 1 PROCEEDED INTO DITCH AND STRUCK A TREE. UNIT 1 SUSTAINED MAJOR DAMAGE TO FRONT END. BOTH
DRIVER AND PASSENGER WERE TRANSPORTED TO HOSPITAL FOR MINOR INJURIES. VEHICLE WAS TOWED DUE TO DAMAGE. ICE COVERED ROADS AND WEATHER CONDITIONS WERE A FACTOR IN THIS INCIDENT.
Accident Report
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MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDTZ9L 3 4
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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
01/15/2016
132 - Date Notified 0934133 - Time Notified (Military Time)1011134 - Time Arrived (Military Time)
01/24/2016
135 - Date Of Report
16011501 16011501 19 - Special Study
18 - Agency Space
Accident Report
of
MV4000e 01/2005
Page
PK2012
Wisconsin Motor Vehicle GZDTZ9L 4 4