HomeMy WebLinkAbout2026-00036185 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO042M68
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and f or Tow Due To Crash YR 202612026-00036185 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE 0 Y ®N 06 22 2026 ❑AM ❑YES ®NO U1
S MCLEAN BLVD Elgin mo /day/yr 02:16 ®PM FLOW CONDITION I'n
_
10(� COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
® �C.7!MI N E O W Route 20 WITH VEHICLES INVLD ® STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑NCv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
Davis.Tashauna.C. 0 5
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 (E <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 m
F 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 2 ALGN =
❑ 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
r 6 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI �i COM VEH El Ea 1
Z ELGIN IL 60123 0 1 0 FY78474 IL FIRST CONTACT 1 T : __s Yeg.See Sidebar u1 0
Ismi
TELEPHONE
IL D 5NPDH4AE2CH098421 American Alliance ❑Y Il N U2 m
2. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Woods. Deshawn. M. ILAA-1141171-00 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
m g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NMv 0 NCv ❑DV
1 9 6 6 Chevrolet Colorado Pickup 2016 00-NONE 11"I t2..-_, DUE TO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 10'I !. 2 FIRE ID ElU2 C
70
M 2 4 SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 X
❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistrac) 0 n Value U1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 . 6 Il:; COM VEH ❑ ® CO
F,,, FIRST CONTACT 7 O7 -5 •If Yes.See Sidebar
SOUTH ELGIN IL 60177 0 1 0 4052452B IL REAR C
0
IL D 1 GCHSBE38G1377630 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 0777217-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 06,22 /2026 02 16 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 ❑ 03 45 I / 0 PM ❑Construction *
, G
Z3 0 0 CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
o ® 11 1 ARREST NAME Davis.Tashauna.C. 11-601 345000301 ) r El PM SLMT
o N ElCITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
30
t 2 0 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
345-Gomoll.Geoffrey 702 331-Ziegler , / ❑PM ®N U2
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.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
h Has a weight rating more than 10,000 pounds(example:truck or truckrtrarler -<
} } - ' I N r INDICATE NORTH combination):or —I e
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
C
�A, } (example:shuttle or charter bus):or 0
I- I- --I-•--; ,�d tran0
sporting emned to ploaeesl5 or fewer In the course of passengers
er empltlmeent operated
xample:employee a contract ner X
} F � po n9 employees ICY
Li / transporter-usually a van type vehicle or passenger car):or CO
L i.-----}----; NY2 1 - } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. (I)1 for direct compensation(example:large van used for specific purpose):or 0
L L____a____. t i i , 5. Is any vehicle used to transport anyhazardous material rn
placarding(example:placards will be displayed on the vehicle). ;p
/ --
i CARRIER NAME Z
1 r r -1- 1II ADDRESS 0
V)
1 C
3 CITY/STATE/ZIP g
I _ MOTOR CARR.ID 0 Interstate 0 Intrastate
_Not To Scale J t� ••► O
I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
0
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE