HomeMy WebLinkAbout2024-00060380 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets 1IH1IlOII III I
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
El NOT ON SVEHICLE/PROPERTY inOVER$1.500 ❑AMENDEDCENE(DESK REPORT) Ill B Injury and/or Tow Due To Crash YR 2024I2024-00060380 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 'IT
POPLAR CREEK DR ® ❑
Elgin RELATED ®Y 0 N 09 20 2024 03:08 ❑AM ❑YES ®NO U1 .(
PRIVATE mo /day I yr ®PM FLOW CONDITION m
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) PEDALCYCUST® ® FREE FLOW # LNS 0
❑DRNER ❑ PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES ❑SIN ❑Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N n
/ / FOR DAMAGED AREA(S) FRONT_ TOWED U1 0
00-NONE 11 12 1 DUE TO CRASH El ❑
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1 2 FIRE 0 0
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 0 U2 m
9 16-TOP 3
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❑Y ❑N ❑UNK VEH. AT CRASH POINT UNKNOWN
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❑DRNER El PARKED 0 DRNERLESS El PED ❑PEDAL ❑EQUES 0 WV ❑Rcv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
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NAME(LAST,FIRST,M) mo day yr 00-NONE 11 12 Z1
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N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61_5 CIOMe6 VEH
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(UNIT) (SEAT) ;DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z
N 1 El 09/20 /2024 03 08 ®pm in a Work Zone? El DIRP co
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PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 C)
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co ! I PM El Construction *
N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
ARREST NAME Castaneda. David.O. 11-407-A 1527000207 / / ❑PM SLMT
,- U 1 CITATIONS ISSUED PENDING •
ROAD CLEARANCE TIME 0 Utility
o N SECTION CITATION NO. AM
2 0 ARREST NAME 09/20 /2024 04 00 El RA0 Unknown work zone type U1
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OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 ❑ 1527-Juarez.Jorge 302 334-Fries 09 122/2024 01 30 0 PM workers present? ®Y
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REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
. 0
' } A CMV is defined as any motor vehicle used to transport passengers or property and. Z
r-"--r--- 4 , 4 r r r r r , , , 1 . r
1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -<
r i ; i r r , , i r r INDICATE NORTH combination) or —I
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I ' t ` ` ' ' 1 ` ` r r r (example'.shuttle or charter bus)-or
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3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i------.-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee M
transporter-usually a van type vehicle or passenger car).or 03
' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver,
9 Po P 9 N
for direct compensation(example:large van used for specific purpose).or O
i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example placards will be displayed on the vehicle) 11
CARRIER NAME Z
' ADDRESS 0
N
• CITY/STATE/ZIP
, ,
MOTOR CARR ID ❑ Interstate ElIntrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
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, Source of above Z
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. ❑ Yes ❑ No ❑ Unknown D
Did Carrier Safety Regulations(MCS)violation contribute to the crash
❑ Yes 0 No ❑ Unknown A
C
Was a driver/vehicle Examination Report Form completed? D
HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No -
MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No
Form Number 0
m
X1
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
m
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ 0
U COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
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• - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
UTOWED ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO
DUE TO SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO:
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE