FLORIDA TRAFFIC CRASH REPORT HIGHWAY SAFETY MOTOR VEHICLES TRAFFIC CRASH RECORDS LONG FORM IXI SHORT FORM l:l UPDATE NEIL KIRKMAN BUILDING, TALLAHASSEE, FL 32399-0537 (Electronic Version) Crash Date Time of Crash Date of Report Reporting Agency Case Number I-IEIMV Crash Itepurt Number OCTOBER 15. 2017 10:00 AM OCTOBER 15, 2017 081710001139 87088155 I I I County Code City Code County ofErash Piece or City of Crash Within City Limits Time Reported Time 10 79 BROWARD WESTON YES 10:12 AM 10:12 AM Time on Scene Time Cleared Scene Completed 10:15 AM 12:15 PM ROADWAY INFORMATION ONLY 1 OF 4 OPTIONSI Henson [if Investigation NOT Complete] Notified By LAW ENFORCEMENT Crasli Occurred On Street, Road, Highwa AI: Slruui At Latitude And Longitude STANTON DR 816 0 At Feet Miles Direction '0 At/ From Intersection With Street' Road, Highway [0 Or From Milepost it Road System identifier Type of Shoulder Type of Intersection 5 LOCAL 3 CURB 1 NOT AT INTERSECTION CRASH INFORMATION IF PICTURES TAKENI in Light Condition Weather Condition Roadway Suriace ConriitiOn School Bus Related Manner of Collision 1 DAYLIGHT 1 CLEAR 1 DRY 1 N0 77 OTHER (EXPLAIN IN First Harmful Event Type First Harmful Eyent First Harmful Event Location Within Interchange First Harmful Event Relation to Junction 2 COLLISION WITH NON-FIXED 13 COLLISION WITH ANIMAL 1 ON ROADWAY 1 NO 1 NON-JUNCTION OBJECT Contributing Circumstances: Road Contributing Circumstances: Road Contributing Circumstances: Road 1 NONE Contributing Circumstances: Environment Contributing Circumstances: Environment Contributing Circumstances: Environment 1 NONE Work Zone Related Crash Work Zone Type OfWork Zone Workers In Work Zone- an Enforcement In Work Zone 1 N0 Check if Commercial I Vehicle Motor Vehicle Type Hit and Run Veh License Number 01 1 VEH IN TRANSPORT 2 YES Reg. Expires DECEMBER 31. 2017 Jrierrncu'II-Jnt Reg. VIN Year Make Model Style Color Extent of Damage Est Damage Towed Due To Damage Vehicle Removed By Rotation 2016 NISS WHI 3 NONE 1 NO DRIVER Insurance Company (Driverj Insurance Policy Number NAVIGATION CH16CAL02016000 Name of Vehicle Owner (Business) '2 Current Address City State Zip Code IMPACT SHIPPING SOLUTIONS 1900 NW 132 PL MIAMI. FL 33169 Trailer License Number State Rep, Expires Permanent Reg VIN Year Make Length Mics Dne: Trailer License Number State Reg. Expires Permanent Iteg. VIN Year Make Lengtii Axles wo: Vehicle Direction On Street, Road. Highway At Est. Speed Poster! Spec-d Total Lanes Traveling STANTON DR i15 15 02 CMV Configuration Cargo Body Type 3 VANIENCLOSED BOX Area Of Initial Impact Most Damaged Area Comm Trailer Type (Trailer One) Trailer Type (Trailer Two) 7 13 Undercarriage Overturn 19 3 20 Windshield 20 1 1?5 17 3 Haz Mat. Release Haz. Mat. Placard Number Class TH- 21 Trailer 21 9 14 13 12 11 109 Motor Carrier Name DDT Motor Carrier Address City State Zip Code Phone Number Comm/Non-Commercial Vehicle Body Type Vehicle Defects {one} Vehicle Defects (two) Emergency Vehicle Use Special Function of MV 17 CARGO VAN (10,000 LBS 1 NONE 1 NO 1 NO SPECIAL OR FUNCTION Maneuver Action Trafficway Roadway Gracie Roadway Alignmenl Most Harmful Event Most Harmful Event Detail 1 STRAIGHT AHEAD 1 TWO-WAY. NOT ?i LEVEL 1 STRAIGHT 2 COLLISION WITH 13 COLLISION WITH ANIMAL NON-FIXED OBJECT Traffic Control Device For This Vehicle First (1) Sequence Of Events Second (2) Sequence of Events Third Sequence of Events Fourth Sequence of Events 1 NO CONTROLS 13 COLLISION WITH ANIMAL HSMV 90010 Page 1 of 3 Crash Date lime cil Crash {Jute cal Repolt Agency Case Number Crash Report Number OCTOBER 15, 2017 10:00 AM OCTOBER 15, 2017 081710001139 87088155 Person II Description lVehicle it Name Date of Birth Phone Number 01 1 DRIVER 01 NIURKA I. PEREZ AUGUST 23. 1956 339-5874 2 N0 Address City 3.: State Ii): Code 10357 SW 174TH TER MIAMI. FL 33157 Driver License Number State Expires DI. Type Req. End. Injury Severity Ejection P620629668080 LFL AUGUST 28. 2021 5 I OPERATOR 2 N0 1 NONE 1 NOT EJECTED Restraint Systems Air Bag Deployed Helmet Use Protection Seating Location Seat Seating Location Row Seating Location Other 3 SHOULDER AND LAP 2 NOT DEPLOYED 3 NOT 1 LEFT 1 FRONT 1 NOT APPLICABLE BELT USED APPLICABLE Drivers Actions at Time at Crash (First) Drivers Action: at Time all Crash [Second] Driver Distracted By Vision Obstruction 1 NO CONTRIBUTING ACTION 1 NOT DISTRACTED 1 VISION NOT OBSCURED Drivers. Actions at Time 0! Crash (Third) Drivers Action: at Tlrne of Crash (Fourth) Drivers Condition at Time of Crash 1 APPARENTLY NORMAL Suspected Alcohol Use Alcohol Tested Alcohol Test Type Alcohol Test Result BAC Suspected Drug Use Drug Tested Drug Test Type Drug Test Result 1 N0 1 NO Source of Transport to Medic-1 Facility 1 NOT TRANSPORTED EMS Agency Name or ii] EMS lion Number Medical Facility Transported To Phone Number Name Date All Birth Irliurv Severity Person ll Description 02 2 NON-MOTORIST DEBRA B. KEARNS SEPTEMBER 27. 1968 (9541 240-7834 Address City State Zip Code 816 STANTON DR WESTON, FL 33326 Non-Motorist Description Detail Non-Motorist Action Prior to Crash Non-Motorist Location at Time of Crash 1 PEDESTRIAN 77 OTHER (EXPLAIN IN NARRA11VE) 7 SHOULDERIROADSIDE Non-Motorist Actions/Circumstances (First) Non-Motorist Actions/Circumstances (Second) Non-Motorist Safety Eqmpment (One) Non-Motorist Sarety Equrpment (Two) 77 OTHER (EXPLAIN IN NARRATIVE) 1 NONE Suspected Alcohol Use Alcohol Tested Alcohol Test Type Alcohol Test Result BA: Suspected Drug Use Drug Tested Drug Test Type Drug Test Result 1 NO 1 NO Source of Transport to Medical Facility EMS Run Number Medical Facility Transported To 1 NOT TRANSPORTED ?u'l OLA Person it 01 EMS Agency Name or ID Vehicle? Est. Amount 02 $500 Business Owner's Name Address City 3.: State zip Code 2 NO DEBRA B. KEARNS 816 STANTON DR WESTON. FL 33326 NARRATIVE The Driver of Vehicle #1 (Amazon package Shipping Solutions) stated that she was traveling southbound on Stanton Drive when she observed a woman (listed as pedestrian) with an unleashed dog on the west side of the roadway. The Driver stated that she then moved to the left side of the roadway to give the Pedestrian and dog more space. The Driver stated that as she passed them, she heard the Pedestrian screaming and banging on her vehicle. Vehicle #1 then stopped in the roadway. The Pedestrian then walked up to the driver?s door of Vehicle #1 and continued banging on the door and window while yelling "you ran over my dog, get out of the van". The Driver of Vehicle #1 stated that she was terrified and did not know what the Pedestrian might do next, so she fled the area and called her boss. The Driver stated that her boss told her to come back to her office. The Driver stated that she then left the area 1 911 Caller The Driver stated she did not know that she hit the dog until the Pedestrian started yelling at her. The Driver stated that she did not see anyone else in the area during this incident. The Womaanedestrian stated that she was attempting to load her two boys and her dog into her vehicle that was parked properly in her driveway. The Pedestrian stated that her dog was not on a leash and one of her sons is autistic. The Pedestrian stated that one of her sons was in her vehicle. her dog was on the sidewalk with her and her autistic son was standing next to a tree on the east side of the roadway. The Pedestrian stated she observed a white van traveling southbound at a high rate of speed on Stanton Drive and she started waving her hands in the air and yelling at the Driver of the van to stop. The van then swerved left away from the Pedestrian as her dog ran into the street. The van then ran over the dog, killing it. The van then stopped in the middle of the street and the Pedestrian ran up to the driver?s door yelling at the Driver to get out of the van. The Driver shook her head no and the Pedestrian attempted to open the driver?s door and yelling get out of the van, you just killed my dog. The Driver of the van then fled the area quicker than the Pedestrian could let go of the van?s door handle. The Pedestrian was dragged a short distance and fell to the ground 1 - 911 Caller Fire Rescue #67, Run #3683 responded. They checked the Pedestrian?s left hand and left ankle abrasions. They told her to wash them with worm soapy water. Fire Rescue also assisted the Pedestrian with wrapping her dog in a sheet and placing it into a box while she attempts to call animal control. On 10-15-17 at approximately 1600 hours the Pedestrian call and gave me the phone number for the Driver?s Amazon package delivery company (Impact Shipping Solutions). was the able to make contact with the Driver of Vehicle#1 and she was cited for leaving the scene of an accident with property damage. REPORTING OFFICER IDfEladge Number Plaid. and Name Department 11326 BARNES. B. A. BROWARD COUNTY OFFICE Tvrir.? of Department 2 SO HSMV 90010 Page 2 of 3 Crash Date [mm Crash Dale of Report Repur?tlng Agency Case Number Crash Repnrl Number OCTOBER 15. 2017 10:00 AM OCTOBER 15, 2017 081710001139 87088155 Indicate North A HG Nomiws Drawing NotTo Scale. HSMV 90010 Page 3 of 3 Redaction Date: Friday, July 26, 2019 8:55:30 AM Total Number of Redactions: 2 By Exemption: "ID of caller to "911" - §365.171(12)" (911 Caller): 2 instances By Page: Page 2 - "ID of caller to "911" - §365.171(12)" (911 Caller): 2 instances