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ALCOHOL TEST TYPE

DRUG TEST RESULT(S)

MOTORIST I NON-MOTORIST

UNIT # NAME: LAST, FIRST, MIDDLE DATE OF BIRTH AGE GENDER

1 boy/, Bi .

I 71 [I FADDRESS: STREET, CITY, STATE,ZIP CONTAIT PHONE - ISLUDE AREA CODE

3l ‘nybrook ,L, 4’-?) J% 2/4g /%?%‘C 337

V s yINJURIES INJURED EMS AGENCY (NAME) INJUREDTAKENTD: MEDICAL FACILITY NAMECITY) SAFETYEQUIPMENT SEATING PISIRIN MR BAG USAGE EJECTIIN TRAPPED

TAKEN USED DOT-COMPLIANT’L/ BY j / 4- C’ i. 4? MC HELMET I I I /t L] RerlI iIC(._ I’If I 1 IL_]I I

OL STATE OPERATOR LICENSE NUMBER OFFENSE CHARGED LOCAL OFFENSE DESCRIPTION CITATION NUMBER

j1, ,‘zr3q2 7 331 17

CE

fa1Ic To Yi’-/d %‘13.OL CLASS ENDORSEMENT RESTRICTION SELECTAPTO3 DRIVER ALCOHOL! DRUG SUSPECTED CONDITION ±iuiiiuimi*1 iJIIC1I1f

SECECTUPTO2 DISTRACTED STATUS TYPE VALUE STATUS I TYPE RESULTSELECTUPTO4BY fJ ALCOHOL MARIJUANA

iI IIII L 0 IS I I I I I OTHER DRUG 1 ,i I_____ I I It I

UNIT H NAME: LAST, FtRST, MIDDLE DATE OF BIRTH AGE GENDER

,° MtiJKtt5 ipithy R. iO,/6,/1ci,C7-5 JADDRESS: STREET, CITY, STATE, ZIP CONTAtT PHONE - INCLUDE AREA CODE

i7’5V pd //jr, p/f /c3’ ‘ I ic 5 IINJURIES INJURED AGENCY (NAME) ‘N1UREDTAKEN TO’ MEDICAL FACILITY )NAME,CITY) SAFETY EQUIPMENT SEATING PISITIIN AIR BAG USAGE EJECTIIN TRAPPED

. TAKEN USED I’I DOT-COMPLIANTBYJ A’ L]MC HELMET

, J 2. , /

DL STATE OPERATOR LICENSE NUMBER OFFENSE CHARGED LOCAL OFFENSE DESCRIPTION CITATION NUMBERCODEoh’, o3 0

OL CLASS ENDORSEMENT RESTRICTION SELECT UPTOD DRIVER ALCOHOL! DRUG SUSPECTED CONDITION iruiuic’ I*1 hIIIII*14jSELECT UPTO 0 DISTRACTED STATUS TYPE VALUE STATUS TYPE RESULT stooct spool

BY fl ALCOHOL MARIJUANA,

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TAKEN USED t9D0T0MLIT

_______

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‘—‘MC HELMET , , / I I , L_i_ ‘OL STATE OPERATOR LICENSE NUMBER OFFENSE CHARGED LOCAL OFFENSE DESCRIPTION CITATION NUMBER

CODE

oft, UDL CLASS ENDORSEMENT I RESTRICTION SELECTUPTOT DRIVER ALCOHOL! DRUG SUSPECTED CONDITION u11’ *1

SELECT UPTO2 DISTRACTED STATUS TYPE VALUE S IATUS TYPE RESULT SELECTOPTO4

BY ALCOHOL MARIJUANA

I I III) 0 I I I OTHER DRUG I cJ • I______

11!I 11* INSIiIIISLFIO?IIIIJI U1I:Y:t. IJl41OC t(]I •IJlL’A l)IN Rot ‘ii• *1it:WI

1- FATAL 1- FRONT— LEFT SIDE 1- NOT DEPLOYED 1- CLASSA 1 -ALCOHOL INTERLOCK DEVICE 1- NOT DISTRACTED 1- NINE GIVEN(MOTORCYCLE DRIVER)2-SUSPECTEDSERIOUSINJURY 2-DEPLOYEDFRONT 2-CLASSB 2-CDLINTRASTATEONLY 2-MANUALLYOPERATINGAN 2-TESTREFUSED

2-FRONT—MIDDLE3- SUSPECTED MINOR INJURY 3- DEPLOYED SIDE 3- CLASS C 3- CORRECTIVE LENSES ELECTRONIC COMMUNICATION 3 -TEST GIVEN, CONTAMINATED3- FRONT- RIGHT SIDE DEVICE )TEXTING,TYPING, SAMPLE) UNUSAOLE4- POSSIBLE INJURY 4- DEPLOYED BOTH FRONT/ SIDE 4- REGULAR CLASS 4- FARM WAIVER DIALING)4- SECOND — LEFT SIDE (OHIO = DI 4 -TEST GIVEN, RESULTS KNOWN5- NOAPPARENT INJURY 5- NOTAPPLICABLE 5- EXCEPT CLASS A BUS 3 -TALKING ON HANDS-FREE(MOTORCYCLE PASSENGER) 5- M)C MOPED ONLYV - DEPLOYMENT UNKNOWN & - EXCEPT CLASS A COMMUNICATION DEVICE S -TEST GIVEN, RESULTS

UNKNOWN5- SECOND— MIDDLE 6- NO VALID IL & CLASS B lOS 4 -TALKING ON HAND-HELD6- SECOND— RIGHT SIDE1- NOITRANSPORTED 7- EXCEPTTRACTOR-TRAILER COMMUNICATION DEVICE

(TREATED AT SCENE 7 -THIRD - LEFT SIDE 0 - INTERMEDIATE LICENSE 5 -OTHER ACTIVITY WITH AN1-NONE(MOTORCYCLE SIDE CUR)2- EMS 1- NOT EJECTED H - HAZMAT RESTRICTIONS ELECTRONIC DEVICE

I-THIRD-MIDDLE 2-BLOOD3- POLICE 2- PARTIALLY EJECTED U - MOTORCYCLE 9- LEARNERS PERMIT 6- PASSENGER9 -THIRD — RIGHT SIDE RESTRICTIONS 7- OTHER DISTRACTION 3- URINE

9- OTHER/UNKNOWN 3-TOTALLY EJECTED P - PASSENGER10- SLEEPER SECTION 00- LIMITEOTO DAYLIGHT ONLY INSIDETHE VEHICLE 4- BREATH

4- NOTAPPLICABLE N -TANKEROFTRUCK CAB 01- LIMITEDTO EMPLOYMENT U - OTHER DISTRACTION OUTSIDE 5- OTHER

U- MOTOR SCOOTER THE VEHICLE1- NINE USED II- PASSENGER IN OTHER 02- LIMITED — DTHER

ENCLOSED CURGOAREA H -THREE-WHEEL MOTORCYCLE 9-OTHER! UNKNOWN2- SHIULOER BELT ONLY USED (NON-TRAILING UNIT, BUS, 1- NOTTRAPPED S - SCHOOL BUS 13- MECHANICAL IEVICES

1- NONE3- LAP BELT ONLY USED PICK-OP WITH CAP) 2- EXTRICATEI BY (SPECIAL BRAKES, HAND

I - DOUBLE &TRIPLETRAILERS CONTROLS, OR OTHER 2- BLOOD4- S000LOER & LAP BELT USED 12- PASSENGER IN UNENCLOSED MECHANICAL MEANS

CARGOAREA 3- FREED BYX-TANKER/ HAZMAT AOAPTIVE DEVICES) 1 -APPARENTLY NORMAL 3- URINE

5- CHILI RESTRAtNT SYSTEM— 14- MILITARY VEHICLES ONLY 2- PHYSICAL IMPAIRMENT 4• OTHERFORWARD FAC)VG 13 -TRAILING UNIT NON-MECHANICAL MEANS

15- MOTOR VEHICLES WITHOUT 3 - EMOTIONAL (ES, DEPRESSED,6- CHILD RESTRAINT SYSTEM — 14- RIDING ON VEHICLE EXTERIORAIR BRAKES ANGRY, DISTURBED)

REAR FACING NON-TRAILING UNIT)06- IOTSIDE MIRROR 4- ILLNESS 1 -AMPHETAMINES

7 - BOOSTER SEAT 15- NON-MOTORIST07- PROSTHETIC AID 5 FELL ASLEEP, FAINTED, 2- BARBITURATES

B -HELMET USED 99-OTHER/UNKNOWNFATIGUED, ETC.lB - OTHER 3- BENZODIAZEPINES9-PROTECTIVE PADS USED 6- ONDERTHE INFLUENCE

(ELBOW, KNEES, ETC.( OF MEDICATIONS / ORUGS 4- CANNABINOIDS

DO - REFLECTIVE CLOTHING (ALCOHOL 5- COCAINE

Dl - LIGHTING — PEDESTRIAN 9-OTHER) UNKNOWN 6-OPIATES) OPIOIDSI BICYCLE ONLY 7- OTHER

99-OTHER/UNKNOWN B-NEGATIVE RESULTS

PAGE OF(

U NIT

UNIT # OWNER NAME: LAST, FIRST, MIDDLE (VAMEADDRIVER)

ID))OWNER ADDRESS: STREET, CITY, STATE, ZIP )VAMEAS DRIVER)

COMMERCIAL CARRIER: NAME,ADDRESS, CITY, STATE, ZIP

OWNER

I I I I i I I I

LOCAL REPORT NUMBER

I/IqII9IlI1I I I I

LP STATE LICENSE PLATE # VEHICLE IDENTIFICATION # — VEHICLE YEAR VEHICLE MAKE

OIñ I cyK273G., IKMItIDLWI’/IIDFgI1DILLI3I7III%bI It 01O16,1 Hyttndaj

IDMMERCIAL CARRIER PHONE: INCLVDE AREV CSDE

I I ) F I I I I t

DAMAGE SCALE

1-NONE 3-FUNCTIONALDAMAGE

I 7 I 2- MINOR DAMAGE 4-DISABLING DAMAGE

9- UNKNOWN

DAMAGED AREA(S)INDICATE ALLTHAT APPLY

INSIRANCE INSURANCE COMPANY I INSURANCE POLICY # COLOR I VEHICLE MODELVERIFIED StQ1_ Fc&(m cC5/1Lko73S sj]yer Ekn1ro

TYPE OF USE US DOT R TOWED BY: CSMPARV RAME

G IN EMERGENCY I RtAer 3NAZARDDUS MATERIAL

INTERLOCK I #OCCUPANTSVEHICLE WEIGHT GVWR/GEWR

MATERIAL CLASS # PLACARD ID #

COMMERCIAL UGOVEINMENT RESPONSE I I I I

cI DEVICE HIT/SKIP UNIT -

- LRS. RELEASED2 - 10,001- 26K LRSEQUIPPED 10:11 CPLACARD I I I

1 - PASSENGER CAR 7- MOTORCYCLE 2-WHEELED 12 -GOLF CART 08- LIMO (U VERY VEHICLE) 23-PEIESTRIAN (SKATER

2 - PASSENGER VAN )MINWAN) I - M050RCVCLE 3-WHEELED 13-SNOWMOBILE 19-lAS (16+ PASSENGERS) 24-WHEELCHAIR)ANYTVPE)

3- SPORT ATILITY VEHICLE 9- A6TOCVCLE 14-SINGLE ONITTROCR 20-OTHERVEHICLE 25-OTHER NON-MOTORISRUNITTYPE 4- PICKUP DO-MOPEDOR MOTORIZED 15-SEMI-TRACTOR 21-HEAVYEOUIPMENT 26-BICYCLE

S - CARGO VAN OICYCLE 16 -FARM EQUIPMENT 22 -ANIMAL WITH RIDER OR 27 -TRAIN

6- VAN 9-15 SEATS) ID -ALLTERRAIN VEHICLE 17- ROTORHOME ANIMAL-DRAWN VEHICLE 99- ANKNOWN OR HIT)SKIP)ATV) ATV)

)___j # orTRAILING UNITS

)N’ASVEHICLEOPERARING IN AUTONOMOUS 0 - NOA000MATION 3- CONDITIONALAATOMATION 9- ANKNOWNMODE WHEN CRASH OCCURRED? D - DRIVER ASSISTANCE 4- HIGHAATOMATION

1 -YES 2- NO 9- OTHER) ONKNOWN 2- PARTIALAATOMATION S - FOLLAL’TOMATIONAUTONOMOUSMODE LEVEL

1- NONE A - BOS—CHARTERITOOR 11-FIRE 16-FARM 2D-MAILCARRIER

2- TAHI 7 - HAS — INTERCITY 12 -MILITARY 17 -MOWING 99 -OTHER) ANKNOWN

3 - ELECTRONIC RIDE SHARING B- BUS— SHOULE 13- POLICE DI -SNOW REMOVALSPECIALFUNCTION - SCHOOLTRANSPORT 9- BUS—OTHER 14-PABLIC ATILITV 19-TOWING

5 - HAS —TRANSIT)COMHUTER 10 -AMBOLANCE 15 -CONSTRUCTION EOOIPMENT 20 -SAFETY SERVICE PATROL

1- NO CARGO DODVTVPE 3- VEHICLETOWINGANOTHER 5- INTERMOOAL CONTAINER 8 - POLE 12-CONCRETE MIVER1_çf )NDTAPPLICADLE MOTOR VEHICLE CHASSIS 9- CARGOTANK D3-AATOTRANSPORTERCARGO 2- HAS 4- LOGGING 6- CARGO VAN)ENCLDSED IDA

DDDY DO-FLATBED D4-GARBAGDREFUSE

TYPE 7 - GRAIN)CHIPS)GRAVEL U - DAMP 99 -OTHER) ONRNOWN

1 - TARN SIGNALS 4 - ORAKES 7 - WORN OR SLICKTIRES 9 - M000RTRDADLE 99 -OTHER) ANKNOWNI_

VEHICLE 2 - HEAD LAMPS 5- STEERING I - TRAILER ENAIPMENT DO -DISABLED FROM PRIORDEFECTS 3 - TAIL LAMPS 6- TIRE BLOWOUT DEFECTIVE ACCIDENT

1- INTERSECTION — MARKED 3- INTERSECTION —OTHER 6- BIC VCLE LANE 9- MEDIAN)CROSSING ISLAND 12 -FIRST RESPONDERjj CROSSWALK 4- MIDOLOCK— MARKED 7 - SHOOLDER) ROADSIDE 1O-DRIVEWAYACCESS AT INCIDENT SCENE

HIN-HITIRIST 2- INTERSECTION — ANMARKED CROSSWALK B - SIDEWALK 11 -SHARED USE PATHS OR 99-OTHER) UNKNOWNLOCATION CROSSWALK 5 -TRAVEL LANE—OTHER LOCASSR TRAILSAT IMPACT

12 12 52

3 3

Q-No DAMAGE[O3 D-UNDERCARRIAGE [14]

D-TDP [13] D-ALLAREAS [15]

Q-UNITNDTATSCENE [16]

1 - NON—CONTACT 0 - SYRAIGHTAHEAD 7- MAKING 0-TARN 13 -NEGOTIATING A CURVE 18 -APPROACHING

2- NON-COLLISION 2 - DACKING I - ENTERING TRAFFIC LANE 14- ENTERING OR CROSSING OR LEAVING VEHICLE

LDJ 3-STRIKING 3- CHANGING LANES 9- LEAVINGTRAFFIC LANE SPECIFIED LOCATION 19-STANDING

ACTION 4- STRACK PRECR6SH 4- OVERTAKING)PASSING DO -PARKED 15 -WALKING, RANNING, 20-OTHER NON-MOTORISTACTIONS JOGGING, PLAYING 21 -STANDING OUTSIDES - DOTH STRIKING 5- MAKING RIGHTTARN 11 -SLOWING OR STOPPED

G STRACK U - RAKING LEFTTARN INTRAFFIC 16-WORKING DISABLED VEHICLE

9-OTHER) ANKNOWN 12-DRIVERLESS D7-PASHING VEHICLE 99 -OTHER) ANRNOWN

1 - NONE 7- LEFT OF CENTER 13-IMPROPER START FROM A 17 -VISION OBSTRACTION 21- LYING IN ROADWAY

2- FAILAREVOYIELD 0 - FOLLOWINGTOO CLOSE )ACDA PARKED POSITION DI -OPERATING DEFECTIVE 22- NOT DISCERNIBLE14-STOPPED OR PARKED EQAIPMENT 23 -OPENING DOOR INTO

LJs2J3- RAN RED LIGHT 9 -IMPROPER LANE CHANGE

ILLEGALLY4- RAN STOP SIGN DO-IMPROPER PASSING 19 -LOAD SHIFTING)FALLING) ROADWAY

CIHTRIIRTING 15 -SWERVINGTOAVOID SPILLING 99-OTHER IMPROPERACTION5-UNSAFE SPEED 11-DROVE OFF ROADCIRCAMSTHNCES 16 -WRONG WAY 20-IMPROPER CROSSING6-IMPROPERTURN 12-IMPROPER BACKING

INITIAL POINT OF CONTACT

0- NO DAMAGE 14- UNDERCARRIAGE

I I1-12 - REFERTO UNIT 15-VEHICLE NOT AT SCENE

DIAGRAM 99- UNKNOWN13-TOP

TRAFFIC

TRAFFIC WAY FLOW

1-ONE-WAY

2-TWO-WAY

SEQUENCE OF EVENTS

11 pIo I1 -OVERTURN)ROLLOVER

2 - FIREEVPLOSIDN

— 3 - IMMERSION2h 0 4-JACKKNIFE

5- CARGO)ERAIPMENTLOSS OR SHIFT

31 I

25-IMPACT ATTENAATORC RASH CASH ION

26-BRIDGE OVERHEADSTRUCTARE

6-EQUIPMENT FAILORE

7-SEPARATIONOFANITS

I- RAN OFF ROAD RIGHT

R-RANOFFROADLEU

10-CROSS MEDIAN

TRAFFIC CONTROL

1- ROUNDADOAT 4-STOP SIGN

2 2-SIGNAL S-YIELD SIGN

3-FLASHER 6-NOCONTROL

NON-COLLISION11-CROSS CENTERLINE —

OPPOSITE DIRECTION OFTRAVEL

12- DOWNHILL RUNAWAY

13 -RTHER NRN-COLLISIDN14-PEDESTRIAN15-PEDALCYCLE

#OFTHROUGH LANESON RDAO

16-RAILWAY VEHICLE17-ANIMAL — FARM10-ANIMAL — DEER19-ANIMAL — DINER20-MOTOR VEHICLE IN

TRANSPORT2D-PARRED MOTOR VEHICLE

RAIL GRADE CROSSING

1-NOT INVOLVED

2 - INVOLVED-ACTIVE CROSSING

3-INVOLVED-PASSIVE CROSSING

COLLISION WITH FIXED DRJECT — STRUCK3D -GAARDRAIL END 37-TRAFFIC SIGN POST 43 -CARB32-PORTABLE HARRIER 30-OVERHEAD SIGN POST 44-DITCH33-MEDIAN CABLE BARRIER 39-LIGHT) LUMINARIES 4S-EMBANKMENT

SI I I 34-MEDIAN GUARDRAIL SUPPORT27-BRIDGE PIER OR ABUTMENT BARRIER 40- ATILITY PILE2B-BRIDGE PARAPET 3S-MEDIAN CONCRETE 41-OTHER POST, POLE

61 I I 29-BRIDGE RAIL BARRIER ORSUPPORT

30-GUARDRAIL FACE 36-MEDIAN OTHER BARRIER 42 -CALVERT

_______

FIRST HARMFUL EVENT MOST HARMFUL EVENT

22-WORK ZONE MAINTENANCEEQUIPMENT

23-STRUCK BY FALLING,SHIFTING CARGO ORANYTHING SET IN MOTIONBYA MOTOR VEHICLE

24-OTHER MOVABLE OBJECT

30-WORK ZONE MAINTENANCEEQAIPMENT

51-WALL

52- BAILDING53-TUNNEL

99-OTHER FIAED OBJECT99-OTHER/UNKNOWN

UNIT/ NON-MOTORIST DIRECTION

1-NORTH S - NORTHEAST

2 - SOOTH 6 - NORTHWEST

FROM TO 3 - EAST 7 - SOATHEAST

4 - WEST B - SOOTH WEST

9-OTHER/UNKNOWN

46-FENCE47- MAILBOA

40-TREE49-FIRE HYDRANT

UNIT SPEED

I I ff

DETECTED SPEED

1-STATED/ESTIMATED SPEED

2-CALCULATED)EDR

3-UNDETERMINEDPOSTED SPEED

I 151

HSYR3O4 OHTU 1/19 [760-0020] PAGE OF

‘V OHIO OEPOWRR4RNT I IUNIT

1- INTERSECTION — MARKED

LIIJ CROSS VIALANON-MOTORIST 2- INTERSECTION — UNMARKEDLOCATION CROSSWALKAT IMPACT

0-NON--CONTACT

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1 - OVERTURN/ROLLOVERS p

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3 - IMMERSION

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5-CARGO/EQUIPMENTLOSS OR SHIFT

31 I I

NON-COLLISION00-CROSS CENTERLINE —

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02-DOWNHILL RUNAWAT03-OTHER NON—COLLISION04-PEDESTRIANOS-PEDALCYCLE

22- WORK ZONE MAINTENANCEEQUIPMENT

23-STRUCK IT FALLINS,SHIFTING CARSO ORANYTHING SET IN MOTION0TH M000RTEHICLE

24-OTHER MOVABLE OIJECT

50-WORK ZONE MAINTENANCEEQUIPMENT

51-WALL

52-lU ILDING53-TUNNEL

99-OTHER FITEE OIJECT99-OTHER/UNKNOWN

C-TOP [13]

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12 12 12

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C-ALL AREAS [053

TRAFFIC CONTROL

- ROUNDABOUT 4-STOP SIGN

2- SIGNAL 5-YIELD SIGN

3-FLASHER 6-NOCONTROL

RAIL GRADE CRDSSONG

0-NOT INTOLTEO

2 - INVOLVED-ACTIVE CROSSINS

3 - INHOLTEB-PASSITE CROSSING

UNET H OWNFR NAME: LAST, FIRST, MISSLE EAREAS 1RIVERI OWNER PHONE: RaISE AREA MOE iSAMEOS DRIVER:

I I I I I I I I I I I

OWNER ADDRESS: STREET, CITY, STATE, ZIP IEAOEAD DRIVERI

COMMERCIAL CARRIER: RAME,A000ESS, CITY, STATE, ZIP COMMERCIAL CARRIER PHONE: INCLUDRRREACSSE

I I I I I I P ‘ I I I

r LOCAL REPORT NUMDER

I I I I

LP STATE LICENSE PLATE # VEHICLE IDENTIFICATION # VEHICLEYEAR VEHICLE MAKE

OIL Gvz232 IMJLIS2IAI?IMIrI7IFIBIOIcII7II2IOI)I,5J,/+3LLLII4)?

DAMAGE

DAMAGE SCALE

1-NONE 3-FUNCTIONAL DAMAGE

I 1 2- MINOR DAMAGE 4- DISANLING DAMAGE

9-UNKNOWN

DAMAGED AREA(S)INDICATE ALLTHAT APPLY

I’’’ ‘-

INSURANEE I INSURANCE COMPANY I ENSURANCE POLICY # I COLOR VEHICLE MODELIVERIFIEI AA1q Alewohsrs Select ALLTO o2!/28qg57 c1)yer

TYPE OF USE US DOT H I TOWED DY: CSMFARY SAME

C ON EMERGENCY I________________________________________Li COMMERCIAL GOVERNMENT RESPONSE I I IHAZARDOUS MATERIAL

INTERLDCK I #OCCUPANTSVEHICLE WEIGHT GVWR/GCWR

Ei MATERIAL CLASS # PLACARD ID #EQUIPPED 0) t3->26KL05 - CPLACARD i

D DEVICE HIT/SKIP UNIT1 - OOK LOS. RELEASED2 - 10,000 - 26K LOS

0 - PASSENGER CAR 7 - MOTORCYCLE 2-WHEELED 02-GOLF CAHT lI-LIMO /LIVERTVEHICLE/ 23- PEDESTRIAN / SKATER2- PASSENSERVAN/MINIVAN/ R - MHTTRCYCLE3-WHEELEO 03-SNOWMOBILE 19-RUS/O6+PASSFNGERS/ 24-WHEELCHAIR /ANYTYPE/3- SPORT UTILITY VEHICLE V - AUTOCYCLE 14 -SINGLE UNITTRUCK 20-OTHER VEHICLE 23 -OTHER NON-MOTORIST

UNITTYPE 4- PICKUP OO-VOPEOORMOTOHIZEO OS-SEMI-TRACTOR 21-HEAVYEQUIPMENT 26-BICYCLES - CARGO VAN OICYCLE 16 - FARM EQUIPMENT 22- ANIMAL WITH RIDER SR 27 -TRAIN6- VAN /9-15 SEATSI 01 -ALLOERHAIN VEHICLE 17- MOTORHOHE ANIMAL-DRAWN VEHICLE 99- UNKNOWN OH HIT/SKIP

/AW/UW/

L__J # OF TRAILING UNITS

WAS VEHICLEOPERUTING IN AUTONOMOUS 0 - NOAUTOMATION 3- CONDITIONALAUTOMATION V - UNKNOWNMODE WHEN CRASH OCCURREO/ 0 p

o - ORIVERASSISTANCE 4 - HIGH AUTOMATIONL2_J 0 -YES 2- NO 9- RTHER/ UNKNOWN AUTONOMOOS 2- PARTIAL AUTOMATION S - FULL AUTOMATION

MDDE LEVEL

0 - NONE A - BOS—CHARTEETOUH 10-FIRE 16-FARM 21-MAIL CARRIER

I_?LIJ 2- TAXI 7- BUS — INTERCITY 12- MILITARY 17- MOWING 99-OTHER / UNKNOWN3- ELECTRONIC RIDE SHARING I - BUS — SHUTTLE 13- POLICE 18-SNOW REMOVALSPECIAL

FUNCTION 4- SCHOOLTRANSPORT 9 - BUS —OTHER 14- PUBLIC UTILITY 10-TOWING

5- BUS—TRANSIT/COMMUTER 00-AMBULANCE 15-CONSTRUCTION EOAIPMENT 20-SAFETYSERVICE PATROL

. 0 - NO CARGO BODTTTPE 3- VEHICLETOWINGUNOTHER 5 - INTERMOOAL CONTAINER B - POLE 02-CONCRETE MITERLQJJ_J /NOTAPPLICAILE MOTORVEHICLE CHASSIS 9-CARGOTANK 03-AUTOTRANSPORTERCARGD 2- BUS 4 LOGGING 6 CURGOVAN/ENCLOS[B BOA 00 -FLAT BED 04 -GARBAGE/REFUSEDO DYTYPE 7- SRAIOKICMIPS/GRAVEL 00-BUMP 99-OTHER/UNKNOWN

0 - TURN SIGNALS 4- BRAKES 7 - WORN OR SLICKOIRES 9 - MOTORTROUILE 99-OTMER/ UNKNOANNI_VEHICLE 2- HEAB LAMPS S - STEERING 8- TRAILER EQATPMENT 00 -DISABLED FROM PRIORDEFECTS 3- TAIL LAMPS 6 - TIRE BLOWOUT DEFECTIVE ACCIDENT

5211

3- INTERSECTION —OTHER A - BICYCLE LANE 9- MEOIAN,’CRISSING ISLAND 12-FIRST RESPONDER4- MIBBLOCK— MARKED 7 - SHOULBER/ ROADSIDE 00- DRI XE WHY ACCESS AT INCIDENT SCENE

CROSSWALK I - SIDEWALK 01 -SHARED USE PATHS OR -OTHER/ UNKNOWNS -TRAVEL LANE—OTHER LTCIT::R TRAILS

R A

C - NO DAMAGE [0] C - UNDERCARRIAGE [143

3-STRIKING LPLLJ 3-CHANGING LANESACTION 4- STRUCK POE-CRASH 4-OVERTAKING/PASSING

5- BOTH STRIKING ACTIDNSS - MAKING RIGHTTURN

ASTRUCO 6- MAKING LEFTTURN9-0TH ER/UNKNOWN

O - STMAIGHTAHEAO 7 - MAKING A-TURN

2-BACKING B - ENTCRINGTRAFFIC LANE

9- LCAVINGTRAFFIC LANE

10-PARKED

10-SLOWING OR STOPPCOIN TRAFFIC

12- BOlT CML ESS

03-NEGOTIATING A CURVE

04-ENTERING OR CROSSINGSPECIFIED LOCATION

OS-WALKING, RUNNING,JOGGING, PLATING

06-WORKING

17- PUSHING VEHICLE

C-UNOTNDTATSCENE [161

00-APPROACHINGOR LEAVING VEHICLE

09-STANDING

20-OTHER NON-MOTORIST

21-STANDING OUTSIDEOISAILCO VEHICLE

99-OTHER/UNKNOWN

ONETIAL POINT op CONTACT

0- NO DAMAGE 04- UNDERCARRIAGE

1-12 - REFER TO UNIT OS-VEHICLE NOT AT SCENEI I I DIAGRAM 99-UNKNOWN13-TOP

0 - NONE 7 -LEFT OF CENTER 13 -IMPROPER START FROM A 07 -VISION OUSTRUCTION 21- LVING IN ROADWAY2- FAILURETOVICLB U -FOLLOWINGTOO CLOSE /ACEA PARKED POSITION 08-OPERATING DEFECTIVE 22- NAT DISCERNIBLE

14 -STOPPEO OR PARKED EQOIPMENT 23-OPENING EWR INTO3-RANREDLIGHT 9-IMPROPERLANECHANGEILLEGALLY

4- RAN STOP SIGN 10-IMPROPER PASSING 09 -LOAD SHIFTING,TALLTNG/ ROADWAYCINTRIIUTONG 15 -SWCRVINGTOUVOIO SPILLING 99-OTHER IMPROPER ACTION5- UNSAFE SPEED 00-DROVE OFF ROADEIREUHSTHHCES 16 -WRONG WAY 20 -IMPROPER CROSSING6- IMPROPERTURN 12-IMPROPER BACKING

SEQUENCE0F EVENTS

TRAFFIC

TRAFFIC WAY FLOW- ONE-WAY

- 2 - TWO-WAY

6-EQUIPMENT FAILURE

7 - SEPARATION OF UNITS

I - RAN OFF ROAD RIGHT

9-RANOFFROAD LEFT

10-CROSS MEDIAN

25-IMPACT ATTENUATOR41 I I /CRASM CUSHION

26-BRIDGE OVERHEARSTRUCTURE

06-RAILWAY VEHICLE07-ANIMAL — FARM08-ANIMAL — DEER09-ANIMAL — OTHER20-MOTOR VEHICLE IN

TRANSPORT20-PARKED MOTOR VEHICLE

COLLISION WOTN FOXED DDJECT — STRUCK31-GUARDRAIL END 37-TRAFFIC SIGN POST 43-CURB32-PORTABLE BARRIER 38-OVERHEAD SIGN POST 44-DITCH33-MEDIAN CABLE BARRIER 39- LIGHT/ LUMINARIES 45- EMBANKMENT

SUPPORT 46-FENCE40-UTILITY POLE 47-MUILBOU41-OTHER POST, POLE 40-TREE

OR SUPPORT49-FIRE HYDRANT

42-CULVERT

51 I 99-MEDIANGUARORAIL27 -IRIBGE PIER DR ABUTMENT BARRIER28-BRIDGE PARAPET 35-MEDIAN CONCRETE

RI I P 29-BRIDGE RAIL RUMMIER

30-GUARDRAIL FACE 36- MEDIAN OTHER BARRIER

UNIT/NON-MOTORIST DIRECTION

0-NORTH S - NORTHEAST

LI- 2-SOUTH 6- NORTM WEST

FROM L_LJ TO Ij 3 - EAST 7 - SOUTHEAST

4 - WEST I - SOUTHWEST

9-OTHER/UNKNOWN

I I FERST HARMFUL EVENT L_LJ MOST HARMFUL EVENT

UNIT SPEED

TO-

DETECTED SPEED

1 - ST#TEO/ ESTIMATEB SPEEDIll 2-CALCULATEO/EOM

3 - RNDETERMINC0POSTED SPEED

1S 10,HSYI3D4 OH1U 1/19 [7MO-OO2O) PAGE OF

OHIO OEPAOW000or PAnElS SHEEn NIT

UNIT H OWNER NAME: lAST, FIRST, MIOSLE IQSAME RI DRIVERI

IojJ Ala KaiJ;J’, re5hi zv

COMMERCIAL CARRIER: NAME,AESRESS, CITY, STATE, ZIP

25 IMPACT ATTENUATOR41 I I )CRASH CUSHION

26-BRIDGE OVERHEADSTRUCTURE

SI I 34-MEDIAN GUARDRAIL27-BRIDGE PIER DRABUTMENT IARRIER21- BRIDGE PARAPET 35-MEDIAN CONCRETE

6 I I 25- BRIDGE RAIL BARRIER30-GAARDRAIL FACE 36-MEDIAN OTHER BARRIER

I I FIRST HARMFUL EVENT _L__j MOST HARMFUL EVENT

50-WORK ZONE MAINTENANCEEQUIPMENT

51-WALL52-BA ILDING53-TANNEL54-OTHER FIVED OBJECT99-OTHER/UNKNOWN

UNIT!NON-MOTDRIST DIRECTION

1- NORTH 5- NORTHEAST

2 - SOUTH 6 - NORTH WEST

FROM L___J TO I___L_ 3 - EAST 7 - SOATHEAST

4 - WEST B - SOATH WEST

9- OTHER) ANKNOWN

DETECTED SPEED

- STATED) ESTIMATED SPEED

OWNER ADDRESS: STREET, CITY, STATE, ZIP I jSAMERSDRIAERI

%S) %ant1 P).. MMY7ro&- FqjIj oil’ 1&2

OWNER PHONF tOEAROR CC-3S ClAMORS

aSo,a tag 11q9

LOCAL REPDRT NUMDER

I I

LP STATE LICENSE PLATE # VEHICLE IDENTIFICATION # VEHICLE YEAR VEHICLE MAKE

IoIhJE/.Yti1,2 I2ITHIR-%-2YI’SIcIq[CRI1IaIa7IIZIoIOI5I ‘Ioyo-tot

C:MMERC:AL CARRIER PHONE: INCLUDE AREA CODE

I I I I I I I

DAMAGE SCALE

1-NONE 3-FUNCTIONAL DAMAGE

I ‘.—D I 2- MINOR DAMAGE 4-DISABLING DAMAGE

9-UNKNOWN

DAMAGED AREA(S)INDICATE ALLTHAT APPLY

— .

,.JI’.I%-#IO%IL_

‘‘I - -

INSRRANCE INSURANCE COMPANY I INSURANCE POLICY # I COLOR I VEHICLE MODELIVERIFIED GranQP qio23o s,Thsr cr’ojft.

US DOT H I TOWED BY: COMPANY NAMETYPE OF US

fl IN EMERGENCY IJ COMMERCIAL GOVERNMENT RESPONSE I I I I I I IHAZARDOUS MATERIAL

INTERLOCK I #OCCUPANTSVENICLE WEIGHT GVWRIGEWR

MATERIAL CLASS # PLACARD 10 #1 - 1DK LOS.

EQUIPPED3->26KLBS. ØPLACARD I I

cI OEVREE HITISKIP UNIT

j__ 2-

10,001- 26K LOSRELEASED

S - PASSENGER CAR 7- MOTORCYCLE 2-WHEELED 12-GOLF CART SB-LIMO LIVERY VEHICLE) 23- PEDESTRIAN) SKATER

_j_ 2 - PASSENGER VAN )MINIVAN) 0 - MOTORCYCLE 3-WHEELER 13- SNOWMOBILE 19 - BUS )16’ PASSENGERS) 24- WHEELCHAIR )ANYTYPE)

3- SPORT UTILITY VEHICLE 9- AUTOCYCLE 14-SINGLE ANITTRUCK 20-OTHER VEHICLE 25-OTHER NON-MOTORISTUNIT TYPE 4- PICK UP 10-MOPED OR MOTORIZED 13 -SEMI-TRACTOR 21- HEAVY EOAIPOENT 26- BICYCLE

S - CARGO VAN BICYCLE 16-FARM EQUIPMENT 22-ANIMAL WITH RIDER CR 27-TRAIN

6- VAN 19-b SEATS) 11 -ALLTERRAIN VEHICLE 17 -MOTORHOME ANIMAL-DRAWNVEHICLE 99 -UNKNOWN OR HIT)SKIP)ATV) L’TV)

L__J # orTRAILING UNITS

WAS VEHICLE OPERATING IN AUTONOMOUS 0 - NO AUTOMATION 3 - CONDITIONALAUTOMATION 9 - UNKNOWNMODE WHEN CRASH OCCURRED? 1 - DRIVER ASSISTANCE 4 - HIGH AUTOMATION

101LLJ 1 -YES 2-60 9- OTHER) UNKNOWN AUTDNOMOUO 2- PARTIALAUTOMATIDN S - FALLAUTOHATIONMODE LEVEL

1 - NONE 6- BUS — CHARTER/TOUR 11 -FIRE 16 -FARM 21 -MAIL CARRIER

LP_UJJ2- TAO? 7- BUS — INTERCITY 12 -MILITARY 17 -MOWING 99 -OTHER) UNKNOWN

3- ELECTRONIC RIDE SHARING 0 - BOS — SHUTTLE 13- POLICE 18-SNOW REMOVALSPECIALFUNCTION - SCHOOLTRANSPORT 9- BUS—OTHER 14-PUBLIC UTILITY 19-TOWING

S - RUS—TRANSETCOMMUTER 10-AMBULANCE 15-CONSTRUCTION EOOIPMENT 20-SAFETYSERVICEPATROL

1- NO CARGO BODYTYPE 3- VEHICLEVOWINGANOTHER S - INTERMODALCONVAINER 8- POLE 12-CONCRETE MIUERLLIJ )NOTAPPLICABLE MOTOR VEHICLE CHASSIS 9- CARGOTANK 13-AUTOTRANSPORTERCARGO 2- BUS 4- LOGGING 6- CARGDVAN)ENCLDSEBBOU 10-FLAT BED 14-GARBAGE/REFUSEBODY

7 - GRAIN!CHIPS)GRUVEL 11 -BUMP 99 -OTHER) UNKNOWNTYPE

1- TURN SIGNALS 4- BRAKES 7- WORN OR SLICKTIRES 9- MOTORTROUBLE 99-OTHER)UNKNOWN.1

VEHICLE 2 - HEAD LAMPS S - STEERING B - TRAILER EQUIPMENT 10- DISABLED FROM PRIORDEFECTS 3 - TAIL LAMPS 6- TIRE BLOWOUT DEFECTIVE ACCIDENT

1- INTERSECTION — MARKED 3- INTERSECTION —OTHER 6- BICYCLE LANE 9- MEDIAN/CROSSING ISLAND 12-FIRST RESPONDER___i_ CROSSWALC 4- HIDBLOCK— MARKED 7 - SHOULDER) ROADSIDE 10-DRIVEWAY ACCESS AT INCIDENT SCENE

NIN-MITIRISR 2- INTERSECTION — UNMARKED CROSSWALK B - SIDEWALK 11 -SHARED USE PATHS OR 99-DTHER) UNKNOWNLOCATION CROSSWALK S -TRAVEL LANE—OTHER LATI:R TRAILSAT IMPACT

12 12 12

9 3 9 II

1- NON—CONTACT 1 - STRAIGHTAHEAD 7- MAKING U-TURN 13-NEGOTIATINGA CURVE 10-APPROACHING

2- NON—COLLISION 2- BACKING B - ENTEOINGTRAFFIC LANE 14 -ENTERING OH CROSSING OR LEAVING VEHICLE

3- STRIKING LJ_l_Li 3 - CHANGING LANES 9- LEAVINGTRAFFIC LANE SPECIFIED LOCATION 19-STANDING

ACTION 4- STRUCK PREERASR 4 -OVERTAKING)PASSING 10-PARKED SS-WALKING,RUNNIKG, 20-OTHERNON-MOTORISTACTIONS JOGGING, PLAYING 21 -STANDING OUTSIDES - BOTH STRIKING S - MAKING RIGHTTURN 11 -SLOWING OR STOPPED

6- MAKING LEFTTURN INTRAFFIC 16-WORKING DISABLED VEHICLEGSTRUCH

9-OTHER) UNKNOWN 12 -DRIVERLESS B7-PUSHING VEHICLE 99 -OTHER) UNKNOWN

D-NO DAMAGE [0] D-UNOERCARRIAGE C 141

Q-TOP E131 D-ALLAREAS [151

Q-UNITNOTATSCENE [16]

INITBAL POINT OF CONTACT

0-NO DAMAGE 14- UNDERCARRIAGE

I 1 I1-12 - REFER TO UNIT 15- VEHICLE NOT AT SCENE

DIAGRAM 99 UNKNOWN13-TOP

0 - NONE 7 -LEFT OF CENTER 13 -IMPROPER START FROM A 17-VISION OBSTRUCTION 21- LYING IN ROADWAY

2- FAILURETDYIELD B -FOLLOWINGTDD CLOSE )UCRA PARKED POSITION 10 -OPERATING DEFECTIVE 22- NUT DISCERNIBLE

LØJJ_i3- RAN RED LIGHT 9 -IMPROPER LANE CHANGC 14 -STOPPED DR PARKED EOUIPMENT 23 -OPENING DOOR INTO

ILLEGALLY4- RAN STOP SIGN 10-IMPROPER PASSING 19 -LOAD SHIFI-NGWALLINW ROADWAY

CINTRIBUTING 15 -SWERVINGTOAVOID SPILLING 99-OTHER IMPROPERACTION5- UNSAFE SPEED 11-DROVE OFF ROADCIRCUNSTRNCEI 16-WRONG WAY 20 -IMPROPER CROSSING6-IRPROPERTURN 12-IMPROPER BACKING

S EQU EN C E OF E VE NTS

TRAFFIC

m 1 - OVERTURN/ROLLOVER11 I I

2-FIRE)EHPLOSION

3 - IMMERSION

2L I I 4-JACKKNIFE

S - CARGO) EQUIPMENTLOSS OR SHIFT

31 I I

TRAFFIC WAY FLOW1 - ONE-WAY

2 - TWO-WAY

6-EQUIPMENT FAILURE

7 -SEPARATI000FONITS

8-RAN OFFROADRIGHT

9 - RAN OFF ROAD LEFT

10-CROSS MEDIAN

TRAFFIC CONTROL

1 - ROUNDABOUT 4-STOP SIGN

L—2—J2 - SIGNAL S - YIELD SIGN

3-FLASHER 6-NOCONTROL

or THROUGH LANESON ROAD

HON-COLLISION11 -CROSS CENTERLINE— 16- RAILWAY VEHICLE 22-WORK ZONE MAINTENANCE

OPPOSITE DIRECTION OF 17 -ANIMAL — FARM EQUIPMENTTRAVEL

10- ANIMAL — BEER 23- STRUCK BY FALLING,12 -DOWNHILL RUNAWAY SHIFTING CARGO OR09-ANIMAL — OTHER13 -OTHER NON—COLLISION ANYTHING SET IN MOTION

20- MOTOR VEHICLE IN BY A MOTOR VEHICLE14- PEBESTRIAN TRANSPORT 24-OTHER MOVABLE OOJECT1S-PEBALCVCLE 21-PARKEB MOTOR VEHICLE

RAIL GRADE CROSSING

1-NOT INVOLVED

2 - INNULVER-ACTIVE CROSSING

3-INVOLVED-PASSIVE CROSSING

COLLISION WITH FIXED OBJECT — STRUCK3B -GUARDRAIL END 37-TRAFFIC SIGN POST 43-CURB32-PORTABLE BARRIER 30-OVERHEADSIGN POST 44-DITCH33 -MEBIAN CABLE BARRIER 39- LIGHT) LUMINARIES 4S-EMBANKMENT

SOPPORT 46-FENCE40-UTILITY POLE 47-MAILBOO41-OTHER POST, POLE 40-TREE

OR SUPPORT49-FIRE HYDRANT

42-CULVERT

UNIT SPEED

10 I

POSTED SPEED

Ill 2-CALCULATED)EDR

3-UNDETERMINED

HSYR3O4 OH1U 1/19 [700-0820] PAGE OF (1)

OCCUPANT /WITNEss ADDENDUM

INJURED TAKEN BY

LOCAL REPORT NUMBER

j

__________

—‘—‘—‘I,

UNIT # I NAME: LAST, FIRST, MIDDLE DATE OF BIRTH AGE GENDER

I I I I II I II

ADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CODE

‘ I I

INJURIES INJURED I EMS AGENCY (NAME) I INJUREDTAKENTD: MEDICAL FACILITY (NAME, CITY) I SAFETY EQUIPMENT tSEAT!NG POSITIIN I AIR BAG USAGE EJECTION TRAPPEDTAKEN I I I USEI .—. DOT-COMPLIANT’ IBY I I I L_i MC HELMET I I

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UNIT A NAME: LAST, FIRST, MIDDLE DATE OF BIRTH 1 AGE GENDER

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ADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CDDE

I I I I

INJURIES INJURED I EMS AOENCY (NAME) I INIURESTAKENTO: MEDICAL FACILITY (NAME, CITY) I SAFETY EQUIPMENT SEATING POSITION MR BAG USAGE 1 EJECTION TRAPPED

BY I I I LJMCHELMET ITAKEN I I USED —. DOT-COMPLIANT I

I t..............iI I I I ‘I J_________________I.

UNIT # NAME: LAST, FIRST, MIDDLE DATE OF BIRTH AGE GENDER

I I I I I I I I II

ADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CODE

I I I I I I I I

INJURIES INJURED EMS AGENCY (NAME) I INIUREDTAKENTS: MEDICAL FACILITY (NAME, CITY) SAFETY EQUIPMENT SEATING POSITION I MR BAG USAGE FEJECUDN TRAPPEDTAKEN I USED . DOT-COMPLIANT I IBY I LJMCHELMET I I

I I I I I I I1i______________

UNIT # NAME: LAST, FIRST, MIDDLE DATE OF BIRTH AGE GENDER

I I I I

ADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CODE

I I I

INJURIES INJURED EMS AGENCY (NAME) I INJUREDTAKENTO: MEDICAL FACILITY (NAME, CITY) SAFETYEQUIPMENT ‘SEATING POSITIIN I AIRBAG USAGE EJECTION TRAPPED

BY I L_J MC HELMET ITAKEN USED r7 DOT-COMPLIANT

I I I I III I

rSPECTED

SERIOUS INJURYVEHICLE OCCUPANT (MOTORCYCLE DRIVER)

2- DEPLOYED FRONT

IM 11* tlitEIl110 iIiJ iuIJittIJ

1 FATAL 1-NONEUSED- 1-FRONT—LEFTSIDE 1-NOTDEPLOYED

3- SUSPECTED MINOR INJURY2- SHOULDER BELT ONLY USED 2- FRONT—MIDDLE

%‘i

3- DEPLOYED SIDE3- FRONT — RIGHT SIDE4- POSSIBLE INJURY

3- LAP BELT ONLY USED4- SECOND — LEFT SIDE 4- DEPLOYED BOTH

5- NO APPARENT INJURY4- SHOULDER& LAP BELT USED (MOTORCYCLE PASSENGER) FRONT/SIDE

5- CHILD RESTRAINT SYSTEM — 5- SECOND — MIDDLE 5- NOT APPLICABLEFORWARD FACING 6- SECOND - RIGHT SIDE 9- DEPLOYMENT UNKNOWN

1- NOTTRANSPORTED 6- CHILD RESTRAINT SYSTEM — 7- THIRD — LEFT SIDE/TREATED AT SCENE REAR FACING (MOTORCYCLE SIDE CAR)

8- THIRD — MIDDLE2- EMS 7- BOOSTER SEAT 1- NOT EJECTED9- THIRD — RIGHT SIDE

3- POLICE 8- HELMET USED 2- PARTIALLY EJECTED10- SLEEPER SECTION OFTRUCK CAB9- OTHER/UNKNOWN 9- PROTECTIVE PADS USED 11- PASSENGER IN OTHER ENCLOSED 3-TOTALLY EJECTED

(ELBOW, KNEES, ETC.) CARGO AREA (NON-TRAILING UNIT, NOTAPPLICABLE10- REFLECTIVE CLOTHING BUS, PICK-UP WITH CAP)

12- PASSENGER IN UNENCLOSED11- LIGHTING — PEDESTRIAN

CARGO AREA/BICYCLE ONLY 1- NOTTRAPPED

13- TRAILING UNIT99-OTHER/UNI<NOWN 2- EXTRICATED BY MECHANICAL

14- RIDING ON VEHICLE EXTERIOR MEANS(NON-TRAILING UNIT)

15- NON-MOTORIST 3- FREED BY NON-MECHANICALMEANS

99- OTHER/UNI<NOWN

NAME: CAST, FIRST, MIDDLE DATE OF BIRTH I AGE I GENDER

J10 ,b I

ADDRESS: STREET, CITY, STATE, ZIP CONTACT PHONE - INCLUDE AREA CODE

W4IkIIck Df’. V&Y7,1 t’i4 //2 tt ‘__3 o 3 .2 I 7

NAME: LAST, FIRST, MIDDLE DATE OF BIRTH I AGE I GENDER

I I

ADDRESS: STREET, CITY, STATS. ZIP CONTACT PHONE - INCLUDE AREA CODE

I I I I

NAME: LAST, FIRST, MIDDLE DATE OF BIRTH AGE I GENDER

I I I IIjRESS: STREET, CITY, STATE, ZIP CONTACT PHONE - )NCLUDE AREA CODE

I I I I —

EJECTION

TRAPPED

HSY 8355 CHiP 1/19 1760-1500] PAGE C OF