~TUSEONLY

~"' ..."'. 0'. REPORT ID Agency Report Number

POLICE ONL Y- FORWARD COPY TO

•• "'" YEAR
MONTH DAY HOUR NCIC NO. OFFICERS 10 NO.

1 ADOT TRAFFIC RECORDS SECTION 064R

I
206 S 17th AVE • PHOENIX ARllONA86007-3233 I 1 'I
I I I I I I I I I Total No. of Sheets

Ii, M~!VI~h~;[~)JHETRUCKlBUSSU~~h~MENTIF ANY .~(Circle})}i.'NtJANy)".,~~gl~mond ~RE;;: ,~Ir

"".....
10 Persons ~~ c:>~At L~ast '., IDistrict or Grid No.
2 Total
Units
ITotal
InJunes
I Total. .
Fatalities
I Estimated Totai Damage Compared 10Fata!
to Limit: 0 Over 0 Under D Hit/Run Unit # _ _ _ ,Immediate car~~ from Scene?

:z On Highway/Road / Street D Inside City County

0
0 Outside
3 ~ Intersecting Street, Road / M.P. or R.P. 0 0
(.)
0
North D South I 0 Plus I Distance Measured I 0 Miles
...J 0 At 0 From 0 East D West 0 Minus 0 Approximate 0 Feet

Safety Devices (SO) Air Bag Status (ABS) Injury Severity (IS) Injured (Trans)ported By
0- Not Applicable 4 - Chiid Restraint System 0- Not Applicable 4- Deployed-Other (knee, etc)
1 - No Injury 4 -Incapacitating Injury 0- Not Transported 97- Other
1 - NoneUsed 5 - Helmet Used 1 - Not Deployed 5- Deployed - Combination
2 - Possible Injury 5 - Fatal Injury 1- EMS 99- Unknown
2 - Lap Belt 6 - Other 2 - Deployed - Front 6- Airbag Switch OFF
3 - Non Incapacitating Injury 99 - Not Reported / Unknown 2 - Law Enforcement
3 - Shoulder& Lap Belt99 - UnKnown 3 - Deployed - Side 99 - Unknown

Ejection (Eject) Extraction Direction of Travel (DoT) Lane Roadway Roadway Seating Position
(Extr) Before 1st Crash Event O-Two-Way Continuous Left Turn Grade Alignment
l8-Front Seat - Other (Child in Lap)
1-9 Thru (1 =Median)
~I -Level 1 -Straight 28 or 38-Additional passenger in
O-Not Applicable o -Not N -Northbound NW-Northwest 10-Crosswalk
1~5
2 -Downhill 2 -Curve Left 31 21 11
1 -Not Ejected Applicable S -Southbound NE -Northeast L1 thru Lx-Left Turn (L1=Median) vehicle by row
3 -Uphii', 3 -Curve Right 32 22 12
2 -Ejected, Partially 1 -Extracted E -Eastbound SW-Southwest Rl thnu Rx - Right Turn (R1 =Median) 1 33 23 13 51-In enclosed or cargo area
4 -Hillcrest 99 -UnKnown
3-EJected, Totally 99 -Unknown W -Westbound SE -Southeast BL-Dedicated Bike Lane 38 28 18 52-In unenclosed passenger/cargo area
5 -Sag (bottom)
4-Unknown Degree 99-Unknown HOV-Hlgh Occupancy Vehicle 55-Riding on Vehicle Exterior
99 -Unknown
97 -Non-Roadway 99-Unknown
99-UnKnown
99-Unknown

State I Class I End. 0 DL# D SSN DBoth

IFo Drivel
Pedestrian
Name (First, Middle, Last) Sex

D Pedal cyclist

0
No License/ I Restrictions I Address City State Zip Code I Telephone Number
Permit
Date of Birth Owner/Carrier Name Address City lip Code
o Dnver
S~me as
State

10~~~1~
Plate Number I State Year IBody Style Make Icolor armors I Aaency Use
ci I
z
I- VIN I Trailer (Other Unit) Plate No. State Year GVW (Rated) of
Power Unit Greater
I HazMat Placard?
Z I than 10k pounds? 0Ye~ ONo 0 Y" 0 No
=>
U SO lABS liS
Trans IEject IExtr lOOT [Lane IGrade IAligement I Posted Speed
Limit
otc Est Speed ITransported To
Li:
LL

C2 Removed to (Address/Storage Location Identifier) o Disabled r Removed by I Orders of IEMS 1.0. I Incident No.
I­ o Not Disabled
Insurance Company I Telephone Number (800#) I Policy Number Name of Policy Holder I Elf Date / Exp Date

4 I I o DL#
State Class End. D SSN OBoth
IFo Drivel
Pedestlian
Name (First, Middle, Last) Sex

D Pedalcyclisl

0
No License/ I Restrictions I Address City State lip Code I Telephone Number
Permit
Date of Birth Owner/Carrier Name Address City lip Code
o Driver
Same as
State

Plate Number I State I Year I Body Style Make Icolor <)SUS{9 or morel Aoencv Use
ci seats)
z VIN State Year GVW (Rated) of
I- I Trailer (Other Unit) P.ate No. I HazMat Placard?
Power Unit Greater
Z I than 10k pounds? 0y'¢; ONo 0yes OIJo
=>
U SO lABS liS
Trans IEiect I Extr lOOT ILane ·IGrade rlignment I Posted Speed Ofc Est ITransoorted To
Li: Limit Speed
LL
<I:
a:::
Removed to (Address/Storage Location Identifier) o Disabled IRemoved by I Orders ot !EMS 1.0. I Incident No.
I- o Not Disabled
Insurance Company I Telephone Number (800#) rOliCY Number Name of Policy Holder I Elf Date / Exp Date

Unit # Seat SO ABS IS Trans Eject Extr Name Address City State Zip Code O.O.B. Sex
Pos

rn
a:::
w
5 0
z
w
rn
rn
<I:
c..

Property Damaged I Owner Code1· Private 3 - Federal Government 5 - County in Arizona 7 - Tribal Nation Inventory Tag No. I
(Other than Vehicles) B.ock 22B, Event 21 - 41 10C) 2 - Public Utility (APS, etc) 4 - State of Arizona 6 - City in Arizona 99 ­ Unknown
G (OC) IOwner's Name Address (or Bar Code 10 Number) City State Zip Code I Telephone Number

Photos D Yes I Photographer's Name, 10 Number, and Agency 1,Invest. 0 Yes I Date Invest. 1Time Invest.
Taken ONo atScene 0 No
7 Officer's Signature I Supervisor's Signature IAgency IDate Completed

01-2704 R07/08
 en Name Address City State Zip Code Telephone Number DOB
LJ.J
en
en
LJ.J
8 Z
I­
~
9· CITATION CHARGES 22A­ EVENT
UNIT UNIT SEQUENCE OF EVENTS 22B • CRASH EVENTS
UNIT NO. AR.S. NO. OR CITY CODE FIRST HARMFUL, MOST HARMFUL and
FIRST EVENT SEOUENCEOF
SECOND EVENT NON-COLLISION
1 OVERTURNI ROLLOVER

THIRD EVENT 2 FIRE I EXPLOSION

FOURTH EVENT 3 IMMERSION

4 JACKKNIFE

MOST HARMFUL EVENT BY VEHICLE

(USE CODES 1TO 49) 5 CARGO/ EQUIPMENT LOSSI SHIFT

FIRST HARMFUL EVENTOF CRASH 6 FELL I JUMPED FROM VEHICLE

(USE CODES 1T041 ONLY) I 7 THROWN OR FALLING OBJECT

8 OTHER NON-COLLISION

CHECK ONLY ONE OR ONE BLOCK PER UNIT UNLESS NOTED COLLISION WITH NON·FIXED OBJECT
10· LIGHT CONDITION 16 ·TRAFFIC CONTROL DEVICE 19· VIOLATIONS I BEHAVIOR 9 MOTOR VEHICLE IN TRANSPORT
UP TO TWO CHOICES PER PERSON 10 PEDESTRIAN
01 DAYLIGHT 11 PEDALCYCLE
UN/T# UNIT#
02 DAWN 12 RAILWAYVEHICLE (TRAIN, ENGINE)
1 2 1 2
03 DUSK 13 LIGHT RAILWAY/RAILCAR VEHICLE
o 4 DARK·LlGHTED
0 0 0 NO CONTROLS
CIO 1 SIGNAL
000 NO IMPROPER ACTION 14 ANIMAL, WILD - NON GAME
o 5 DARK-NOT LIGHTED 001 SPEED TOO FAST FOR CONDITIONS 15 ANIMAL, WILD· GAME
o 6 DARK-UNKNOWN LIGHTING
0 0 2 STOP SIGN
0 0 3 YIELD SIGN
002
003
EXCEEDED LAWFUL SPEED
FAILEDTO YIELD RIGHT-OF-WAY
16 ANIMAL - PET
17 ANIMAL - LIVESTOCK
11 • WEATHER CONDITIONS 0 0 4 WARNING SIGN 004 FOLLOWED TOO CLOSELY 18 PARKED MOTOR VEHICLE
0 0 5 RAILROAD CROSSING DEVICE 005 FAILEDTO OBEY STOP SIGN
CLEAR 19 WORK ZONE /MAINT. EQUIP.
0 1 0 0 6 FLASHI NG TRAFFIC SIGNAL 006 FAILEDTO STOP FOR RED SIGNAL
CLOUDY 20 OTHER NON-FIXED OBJ.
0 2 0 0 7 PERSON (Iawenforcemen, crossing guard, O[] 7 DISREGARDED TRAFFIC SIGNAL
SLEET/HAIL (freezing rain/drizzle) COLLISION WITH FIXED OBJECT
0 3 ftagger, etc.) 008 MADE IMPROPER TURN 21 IMPACT AnENUATORI CRASH CUSHION
0 4 RAIN 0 0 97 OTHER [] [] 9 DROVE/RODE IN OPPOSING TRAFFIC LANE 22 BRIDGE/OVERHEAD STRUCTURE
0 5 SNOW 0 0 99 UNKNOWN 0 0 10 KNOWINGLY OPERATED WITH FAULTY!
06 SEVERE CROSSWINDS 23 BRIDGE RAIL
MISSING EQUIPMENT 24 CULVERT
0 7 BLOWING SAND, SOIL, DIRT
17 - MANNER OF CRASH IMPACT 0 0 11 REQUIRED MOTORCYCLE SAFETY
FOG, SMOG, SMOKE 25 CURB
0 8 EQUIPMENT NOTUSED
BLOWING SNOW 26 DITCH
0 9 01 SINGLE VEHICLE 00 12 PASSED IN NOPASSING ZONE 27 EMBANKMENT
097 OTHER o 2 ANGLE (front to side) SAME DIRECTION 00 13 UNSAFE LANE CHANGE 28 GUARDRAIL FACE
099 UNKNOWN o 3 ANGLE (front to side) OPPOSITE DIRECTION 00 14 FAILEDTO KEEP IN PROPER LANE 29 GUARDRAIL END
04 ANGLE (front to side) RIGHT ANGLE 00 15 DISREGARDED PAVEMENT MARKINGS 30 CONCRETE TRAFFIC BARRIER
12· ROAD SURFACE CONDITION 05 ANGLE - DIRECTION NOT SPECIFIED 00 16 OTHER UNSAFE PASSING 31 CABLE TRAFFIC BARRIER
o 6 REAR END (front 10 rear) 00 17 INAnENTIONI DISTRACTION 32 OTHER TRAFFIC BARRIER
01 DRY o 7 HEAD-ON (front-Io-front) 00 18 DID NOT USE CROSSWALK 33 TREE, BUSH, STUMP (STANDING)
02 WET o 8 SIDESWIPE, SAME DIRECTION 00 19 WALKED ON WRONG SIDE OF ROAD 34 TRAFFIC SIGN SUPPORT
03 SNOW o 9 SIDESWIPE. OPPOSITE DIRECTION 1=10 20 ELECTRONIC COMMUNICATIONS DEVICE 35 TRAFFIC SIGNAL SUPPORT
04 SLUSH o 10 REAR-TO-SIDE 00 97 OTHER 36 UTILITY POLE/LIGHT SUPPORT
05 ICE/FROST o 11 REAR-TO-REAR 00 99 UNKNOWN 37 OTHER POST, POLE, OR SUPPORT
06 WATER (standing, moving) o 97 OTHER 38 FENCE
07
08
SAND
MUD, DIRT, GRAVEL
o 99 UNKNOWN
20· CONDITIONS INFLUENCING DRIVER I
39 MAILBOX
40 BUILDING
09 OIL PEDIBICYCLIST
OTHER 41 OTHER FIXED OBJ.
097 18· CONTRIBUTING CIRCUMSTANCES UP TO TWO CHOICES PER PERSON
099 UNKNOWN UP TO TWO CHOICES PER UNIT UN/T# ADDITIONAL SEQUENCE EVENTS
1 2 42 EQUIPMENT FAILURE (TIRE, BRAKE ETC.)
13· RELATION TO JUNCTION UN/T#
1 2 000 NO APPARENT INFLUENCE 43 SEPARATION OF UNITS
00 NOT JUNCTION RELATED 001 ILLNESS 44 RAN OFF ROAD RIGHT
0 0 0 NO CONTRIBUTING CIRCUMSTANCES
JUNCTION NON·INTERCHANGE AREA: ENVIRONMENTAL 002 PHYSICAL IMPAIRMENT 45 RAN OFF ROAD LEFT
01 INTERSECTION 1 GLARE 003 FELL ASLEEP I FATIGUED 46 CROSS MEDIAN
02 INTERSECTION-RELATED 004 ALCOHOL 47 CROSS CENTERLINE
03 ENTRANCE/EXIT RAMP
CIO A SUNLIGHT
005 DRUGS
00 B. HEADLIGHTS 48 DOWNHILL RUNAWAY
04 RAILWAY GRADE CROSSING 2 PHYSICAL OBSTRUCTION(S) 006 MEDICATIONS 49 STRUCK BY FALLING, SHIFTING CARGO OR
05 CROSSOVER-RELATED A. STOPPED IPARKED VEHICLE CHECK ONE IF BLOCKS 4, 5, OR 6 CHECKED ANYTHING SETIN MOTION BY ANOTHER
00
06 FRONTAGE ROAD B MOVING VEHICLE 00 A NO TEST GIVEN VEHICLE
00
07 DRIVEWAY C. LOAD ON VEHICLE 00 B TEST GIVEN 99 UNKNOWN
00
08 ALLEY -ACCESS-RELATED 0 0 C TEST REFUSED
00 D. TREE/SHRUB/BUSH
09 OTHER NON-INTERCHANGE 00 0 TESTING UNKNOWN
o 10 UNKNOWN NON-INTERCHANGE
00 E_ EMBANKMENT
ROAD 0097 OTHER
23· LOCATION OF FIRST HARMFUL EVENT
JUNCTION INTERCHANGE AREA
CIO 3 ROAD SURFACE CONDITiON 100 99 UNKNOWN CONDITION
o 11 THRU ROADWAY
01 ON ROADWAY

o 12 INTERSECTION
0 0 4 DEBRIS 02 SHOULDER

o 13 INTERSECTION-RELATED
0 0 5 RUT, HOLES, BUMPS 21- TRAFFIC UNIT MANEUVER I ACTION 03 ROADSIDE

o 14 ENTRANCE I EXIT RAMP

6 WORK ZONE
A LANE CLOSURE UN/TN
04 OUTSIDE RIGHT-OF-WAY (trafficway)

MEDIAN

o 15 FRONTAGE ROAD
00
00 B. LANE SHIFT/CLOSURE 1 2
05
06 GORE

016 OTHER PART OF INTERCHANGE 001 GOING STRAIGHT AHEAD

o 17 UNKNOWN INTERCHANGE
00
00
C. WORK ON SHOULDER OR MEDIAN
0_ INTERMInENT OR MOVING WORK 002 SLOWING IN TRAFFICWAY 0 7
08
SEPARATOR

IN PARKING LANE OR ZONE

018 UNKNOWN JUNCTION

00 E. OTHER
003 STOPPED IN TRAFFICWAY
o 9 TUNNEL
099 UNKNOWN
00 F. WORKERS PRESENT
004 MAKING LEFT TURN
o 10 BRIDGE
0 0 7 WORN, TRAVEL-POLISHED SURFACE
1005 MAKING RIGHT TURN o 11 OFF ROADWAY (location unknown)
14· TYPE OF INTERSECTION CIO 8 OBSTRUCTION IN ROADWAY 006
007
MAKING U TURN
OVERTAKING/PASSING
o 99 UNKNOWN
0 0 9 CHANGING ROAD WIDTH
00 NOT AT INTERSECTION 008 CHANGING LANES
0 0 10 TRAFFIC CONTROL DEVICE INOPERATIVE,
01 FOUR-WAY INTERSECTION 009 NEGOTIATING A CURVE
MISSING OR OBSCURED 24· LOCATION OF PEDESTRIAN I CYCLIST
02 T-INTERSECTION 0 0 10 BACKING
0 0 11 SHOULDERS (none, low, soft, high)
03 Y·INTERSECTION 0 0 11 AVOIDING VEHIOBJ/PED/CYCLIST/ANIMAL
0 0 12 NON-HIGHWAY WORK MARKED CROSSWALK AT INTERSECTION
INTER.AS PART OF INTERCHANGE 0 0 12 ENTERING PARKING POSITION 01
04 MOTOR VEHICLE
0 0 13 LEAVING PARKING POSITION 02 AT INTERSECTION BUT NO MARKED CROSSWALK
05 TRAFFIC CIRCLE 0 0 13 BRAKES
0 0 14 PROPERLY PARKED 03 NON-INTERSECTION CROSSWALK
06 ROUNDABOUT 0 0 14 STEERING
0 0 15 IMPROPERLY PARKED 04 DRIVEWAY ACCESS CROSSWALK
07 FIVE POINT, OR MORE 0 0 15 POWER TRAIN
1=10 16 DRIVERLESS MOVING VEHICLE 05 SCHOOL CROSSWALK
099 UNKNOWN 0 0 16 SUSPENSION
0 0 17 CROSSING ROAD 06 IN ROADWAY (not in crosswalk/inlersection)
0 0 17 TIRES
0 0 18 WHEELS
CIO 18 WALKING WITH TRAFFIC 07 MEDIAN (but noton shoulder)
0 0 19 WALKING AGAINST TRAFFIC 08 ISLAND
15· TRAFFIC WAY DESCRIPTION CIO 19 LIGHTS (head, signal, tail) 0 0 20 STANDING o 9 SHOULDER
0 0 20 WINDOWS/WINDSHIELD
DO 21 LYING o 10 SIDEWALK
01 ONE WAYTRAFFICWAY CIO 21 MIRRORS 0 0 22 GETIING ON OR OFF VEHICLE o 11 ROADSIDE
02 TWO-WAY, NOT DIVIDED 0 0 22 WIPERS
0 0 23 WORKING ONIPUSHINGVEHICLE o 12 OUTSIDE OF TRAFFICWAY
03 TWO-WAY, NOT DIVIDED WITH A CONTINUOUS 0 0 23 TRUCK COUPLI NGITRAILER/HITCHI
0 0 24 WORKING ON ROAD o 13 DEDICATED BIKE LANE
LEFT TURN LANE SAFETY CHAINS
0 0 97 OTHER o 14 SHARED-USE PATH
0 4 TWO-WAY, DIVIDED, UNPROTECTED (painted> 4 0 0 97 OTHER
0 0 99 UNKNOWN o 15 INSIDE BUILDING
feet) MEDIAN 0 0 99 UNKNOWN CONTRIBUTING o 97 OTHER
05 TWO-WAY, DIVIDED POSITIVE MEDIAN BARRIER
099 UNKNOWN
o 99 UNKNOWN

01-2704 R07/0S BACK

 CONTINUED
· .. REPORT ID Agency Report Number

POLICE ONL Y - FORWARD COPY TO

ADOT TRAFFIC RECORDS SECTION, 064R
206 S. 17th AVE., PHOENIX, ARIZONA 85007-3233 Total No. of Sheets
UNIT 234 a-NONE UNIT a-NONE
Vehicle Damaged Area 10 ­ UNDERCARRIAGE Vehicle Damaged Area 10 ­ UNDERCARRIAGE
25 1EBJS 11-TOTALED 11 -TOTALED
(circle up to three) 97 -OTHER (circle up to three) 97 -OTHER
876 99 -UNKNOWN 99 - UNKNOWN
LATITUDE LONGITUDE

26
ITJITJITJITJ CIIJIIIIITJ
Degrees MirlLJ(es Seconds Degrees Minutes Seconds

D MEASUREMENTS ARTEAPPROXIMATE AND NOT TO SCALE

27 CRASH DIAGRAM D MEASUREMENTS ARE SCALED (SCALE =
INDICATE
NORTH

29 NARRATIVE Describe what happened

t. 01-2704 R7/08
---- --- - - ----

ARIZONA CRASH REPORT Aaencv Reoort Number

NARRATIVE (Continued)
POLICE ONL Y- FORWARD COPY TO

ADOT TRAFFIC RECORDS SECTION, 064R

206 S. 171h AVE., PHOENIX, ARIZONA 85007-3233

CRASH DESCRIPTION
(Narriltive)

INVESTIGATOR'S SIGNATURE DATE

t. 01-2704 R7/08