STATE OF FLORIDA TRAFFIC CRASH
REPORT

LONG FORM

þ

o

o

SHORT FORM
(Shaded Areas)

TOTAL # OF VEHICLE SECTION(S) _____
2

UPDATE

TOTAL # OF PERSON SECTION(S) _____
1

MAIL TO DEPT. HIGHWAY SAFETY & MOTOR VEHICLES,
TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING,
TALLAHASSEE, FL 32399-0537
CRASH DATE

TIME OF CRASH

06/01/2020

DATE OF REPORT

5:24 PM

06/01/2020

CRASH IDENTIFIERS

COUNTY CODE CITY CODE COUNTY OF CRASH

16

50

TIME CLEARED SCENE

5:30 PM

6:28 PM

REPORTING AGENCY CASE NUMBER

HSMV CRASH REPORT NUMBER

20-033187

24022630

þ

PLACE OR CITY OF CRASH

SARASOTA

TIME ON SCENE

TOTAL # OF NARRATIVE SECTION(S) _____
4

þ

CHECK IF
COMPLETED

CHECK IF WITHIN
CITY LIMITS

SARASOTA

REASON (If Investigation NOT Complete)

TIME REPORTED

TIME DISPATCHED

5:24 PM

5:24 PM

Notified By: 1 Motorist
2 Law Enforcement

1

ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS)
CRASH OCCURRED ON STREET, ROAD, HIGHWAY

AT STREET ADDRESS #
1

AT LATITUDE AND LONGITUDE
2

700 BLOCK OF N. LEMON AVE
AT FEET

OR MILES

N

S

E

W

þooo

50

Road System Identifier

5

AT / FROM INTERSECTION WITH STREET, ROAD, HIGHWAY

Type of Shoulder

CRASH INFORMATION (CHECK IF PICTURES TAKEN)
Light Condition

1

1 Daylight
2 Dusk
3 Dawn
4 Dark Lighted

First Harmful Event

14
First Harmful Event
within Interchange

1

1 No
2 Yes
88 Unknown

3

Non-Collision
1 Overturn/Rollover
2 Fire/Explosion
3 Immersion
4 Jackknife
5 Cargo/Equipment
Loss or Shift
6 Fell/Jumped From
Motor Vehicle
7 Thrown or Falling
Object
8 Ran into Water/Canal
9 Other Non Collision

School Bus Related

5 Oil
6 Mud, Dirt, Gravel
7 Sand
8 Water (standing/
moving)
77 Other, Explain
in Narrative
88 Unknown

1

1

1 None
4 Work Zone (construction/
maintenance/ utility)
6 Shoulders (none, low, soft, high)
7 Rut, Holes, Bumps

Crash in Work Zone

5

9 Worn, Travel Polished Surface
10 Road Surface Condition(wet,
icy, snow, slush, etc.)
11 Obstruction in Roadway
12 Debris
13 Traffic Control Device
Inoperative, Missing or Obscured
14 Non Highway Work
77 Other, Explain in Narrative
88 Unknown

Type of Work Zone

1 Before the First Work Zone
Warning Sign
2 Advance Warning Area
3 Transition Area
4 Activity Area
5 Termination Area

Manner of Collision/Impact

Collision with Fixed Object
19 Impact Attenuator/Crash 30 Concrete Traffic Barrier
31 Other Traffic Barrier
Cushion
20 Bridge Overhead Structure 32 Tree (standing)
33 Utility Pole/Light Support
21 Bridge Pier or Support
34 Traffic Sign Support
22 Bridge Rail
35 Traffic Signal Support
23 Culvert
36 Other Post, Pole or Support
24 Curb
37 Fence
25 Ditch
38 Mailbox
26 Embankment
39 Other Fixed Object (wall,
27 Guardrail Face
building, tunnel, etc.)
28 Guardrail End
29 Cable Barrier

1

1

5 Traffic Circle
6 Roundabout
7 Five Point, or More
77 Other, Explain in Narrative

1 No
2 Yes, School Bus
Directly Involved
3 Yes, School Bus
Indirectly Involved 1 Front to Rear
2 Front to Front
3 Angle

First Harmful Event
Location 1 On Roadway

1

1

2 Off Roadway
3 Shoulder
4 Median
6 Gore
7 Separator
8 In Parking Lane or Zone
9 Outside Right of way
10 Roadside
88 Unknown

1

1 None
2 Weather Conditions
3 Physical Obstruction(s)
4 Glare

Workers in Work Zone
1 No
2 Yes
88 Unknown

1 Lane Closure
2 Lane Shift/Crossover
3 Work on Shoulder or Median
4 Intermittent or Moving Work
77 Other, Explain in Narrative

4 Sideswipe, same direction
5 Sideswipe, Opposite Direction
6 Rear to Side
7 Rear to Rear
77 Other, Explain in Narrative
88 Unknown

Contributing Circumstances:
Environment

Contributing Circumstances: Road

5 Railway Grade Crossing
14 Entrance/Exit Ramp
15 Crossover Related
16 Shared Use Path or Trail
1 Non Junction
17 Acceleration/Deceleration Lane
2 Intersection
18 Through Roadway
3 Intersection Related
4 Driveway/ Alley Access 77 Other Location
88 Unknown
Related
1 No
2 Yes
88 Unknown

1 Dry
2 Wet
4 Ice/Frost

Collision-non Fixed Object
10 Pedestrian
11 Pedalcycle
12 Railway Vehicle (train,
engine)
13 Animal
14 Motor Vehicle in Transport
15 Parked Motor Vehicle
16 Work Zone / Maintenance
Equipment
17 Struck By Falling, Shifting
Cargo
18 Other Non Fixed Object

1

Work Zone related

2

1 Not at Intersection
2 Four Way Intersection
3 T Intersection
4 Y Intersection

1

Roadway Surface Condition

4 Fog, Smog, Smoke
5 Sleet/Hail/
Freezing Rain
6 Blowing Sand, Soil,
1 Clear Dirt
Severe Crosswinds
2 Cloudy 7
77 Other, Explain in
3 Rain
Narrative

First Harmful Event Relation to
Junction

1

1
o

Weather Condition

5 Dark Not Lighted
6 Dark Unknown
Lighting
77 Other, Explain in
Narrative
88 Unknown

Type of Intersection

1 Paved
2 Unpaved
3 Curb

OR FROM MILEPOST #

4

BLVD OF THE ARTS

7 Forest Road
8 Private Roadway
9 Parking Lot
77 All other, Explain in
Narrative

4 County
5 Local
6 Turnpike/ Toll

1 Interstate
2 U.S.
3 State

3

1
5 Animal(s) in Roadway
77 Other, Explain in
Narrative
88 Unknown

Law Enforcement in
Work Zone
1 No
2 Officer Present
3 Law Enforcement Vehicle
Only Present

WITNESSES
NAME

ADDRESS

CITY & STATE

ZIP CODE

TELEPHONE

CLAIRE BOREN

710 N LEMON AVE

SARASOTA FL

34236

214-208-9253

NAME

ADDRESS

CITY & STATE

ZIP CODE

TELEPHONE

PAUL JEANOT

710 N LEMON AVE # 127

SARASOTA FL

34236

321-480-0394

NAME

ADDRESS

CITY & STATE

ZIP CODE

TELEPHONE

TOM BARWIN

1565 1ST ST

SARASOTA FL

34236

941-302-2704

NON VEHICLE PROPERTY DAMAGE
VEHICLE # PERSON # PROPERTY DAMAGE –OTHER THAN VEHICLE

EST. AMOUNT OWNER’S NAME (Check if Business)

o ADDRESS

CITY & STATE

ZIP CODE

VEHICLE # PERSON # PROPERTY DAMAGE –OTHER THAN VEHICLE

EST. AMOUNT OWNER’S NAME (Check if Business)

o ADDRESS

CITY & STATE

ZIP CODE

HSMV 90010 S (E) (rev 10/10)
Page ___
1 of ___
8

 VEHICLE #

1

1 Vehicle in Transport
2 Parked Motor Vehicle
3 Working Vehicle
Hit and Run
YEAR
1 No
2 Yes
88 Unknown
INSURANCE COMPANY (Driver)

1

1

Check if Commercial
VEHICLE LICENSE NUMBER

JLWF40

FL
MAKE

2006

o

STATE

REPORTING AGENCY CASE NUMBER

20-033187

24022630

REGISTRATION EXPIRES Check if Permanent VIN
Registration

o 1G6KD57Y66U224190

10/2020

MODEL

STYLE

CADI

INFINITY AUTO INSURANCE COMPANY 109900749171001

o

1

Towed due
to Damage:
1No 2 Yes

2

CURRENT ADDRESS

WILLIE CHARLES SHAW

DAMAGE:
EST. DAMAGE
1 Disabling 4 Minor
2 Functional 88 Unknown
Gray
3 None
$8,000
1. Rotation
VEHICLE REMOVED BY
2. Owner Request
3. Driver
UPMANS
77. Other, Explain in Narrative
ZIP CODE
CITY & STATE

COLOR

4D
INSURANCE POLICY NUMBER

NAME OF VEHICLE OWNER (Check if Business)

HSMV CRASH REPORT NUMBER

1

SARASOTA, FL

1234 17TH ST

34234

TRAILER # LICENSE NUMBER

STATE

REGISTRATION EXPIRES

Check if Permanent VIN
Registration

YEAR

MAKE

LENGTH

AXLES

TRAILER # LICENSE NUMBER

STATE

REGISTRATION EXPIRES

Check if Permanent VIN
Registration

YEAR

MAKE

LENGTH

AXLES

VEHICLE
N
TRAVELING

S

E

W

Off-Road Unknown

þoooo o

HAZ. MAT. RELEASED
1 No
2 Yes
88 Unknown
MOTOR CARRIER NAME

HAZ. MAT PLACARD
1 No
2 Yes
88 Unknown

ON STREET, ROAD, HIGHWAY

N. Lemon Ave1
HAZ. MAT NUMBER

¡¡
¡
¡¡

4

Comm/Non-Commercial
1 Interstate Carrier
2 Intrastate Carrier
3 Not in Commerce/Government
4 Not in Commerce/Other Truck

1 Two Way, Not Divided
2 Two Way, Not Divided, with a
Continuous Left Turn Lane
3 Two Way, Divided, Unprotected
(painted >4 feet) Median
4 Two Way, Divided, Positive Median
Barrier
5 One Way Trafficway
88 Unknown
Trailer Type
TRAILER 1 TRAILER 2 1 Single Semi Trailer
2 Tandem Semi Trailer
3 Tank Trailer
4 Saddle Mount/Trailer
5 Boat Trailer
6 Utility Trailer
7 House Trailer

25

2

35

Most Damaged Area
18 Undercarriage 18
19
19
Overturn
20 Windshield 20
21
21
Trailer

¡
¡¡
PHONE NUMBER

Commercial Motor Vehicle Configuration
1 Vehicle 10,000 lbs or less Placarded
for Hazardous Materials
2 Single Unit Truck (2 axle and GVWR
more than10,000 lbs (4,536 kg))
3 Single Unit Truck (3 or more axles)
4 Truck Pulling Trailer(s)
5 Truck Tractor (bobtail)
6 Truck Tractor/Semi Trailer
7 Truck Tractor/Double Truck
8 Pole Trailer
9 Towed Vehicle
10 Auto Transport
77 Other, Explain in
Narrative
88 Unknown

8 Tractor/Triple
9 Truck more than 10,000 lbs (4,536
kg), Cannot Classify
10 Bus/Large Van (seats for 9 15
occupants, including driver)
11 Bus (seats for more than 15
occupants, including driver)
77 Other, Explain in Narrative
88 Unknown

Cargo Body Type

3 Van/Enclosed Box
4 Hopper
5 Pole Trailer
6 Cargo Tank
1 No Cargo 7 Flatbed
8 Dump
2 Bus
9 Concrete Mixer
1 10,000 lbs (4,536 kg) or less
10 Auto Transport
2 10,001 26,000 lbs (4,536 11,793 kg)
11 Garbage/Refuse
3 More than 26,000 lbs (11,793 kg)
12 Log
4 Not Applicable

Comm

Most Harmful Event

TOTAL LANES

ZIP CODE

Trafficway

15 Low Speed Vehicle
16 (Sport) Utility Vehicle
17 Cargo Van (10,000 lbs
or less)
18 Motor Coach
19 Other Light Trucks (10,000 lbs
or less)
20 Medium / Heavy Trucks (more
than 10,000 lbs (4,536 kg))
21 Farm Labor Vehicle
77 Other, Explain in Narrative
88 Unknown

AT EST. SPEED POSTED SPEED

Area of Initial Impact

CITY & STATE

Vehicle Body Type 13 All Terrain Vehicle (ATV)

1 Passenger Car
2 Passenger Van
3 Pickup
7 Motor Home
8 Bus
11 Motorcycle
12 Moped

HAZ. MAT CLASS

US DOT NUMBER

MOTOR CARRIER ADDRESS

1

o
o

13 Intermodal
Container Chassis
14 Vehicle Towing
Another Vehicle
15 Not Applicable
(vehicle 10,000 lbs
(4,536kg) or less not
displaying HM placard)
77 Other, Explain in
Narrative
88 Unknown

Non Collision
GVWR/GCWR
1 Overturn/Rollover
2 Fire/Explosion
3 Immersion
Collision with Non-Fixed Object
Collision Fixed Object
29 Cable Barrier
Emergency
4 Jackknife
10 Pedestrian
19 Impact Attenuator/Crash Cushion 30 Concrete Traffic Barrier
5 Cargo/Equipment Loss or Shift
Vehicle Use
11 Pedalcycle
31 Other Traffic Barrier
20
Bridge
Overhead
Structure
6 Fell/Jumped From Motor Vehicle
12 Railway Vehicle (train, engine)
32 Tree (standing)
21 Bridge Pier or Support
Sequence of Events
7 Thrown or Falling Object
13 Animal
33 Utility Pole/Light Support
22
Bridge
Rail
8 Ran into Water/ Canal
1st
2nd
14 Motor Vehicle in Transport
34 Traffic Sign Support
23 Culvert
9 Other Non Collision
15 Parked Motor Vehicle
35 Traffic Signal Support
24 Curb
16 Work Zone / Maintenance
36 Other Post, Pole, or Support
[40-46 Sequence of Events only]
25 Ditch
1 No
Equipment
37 Fence
40 Equipment Failure (blown tire,
26 Embankment
2 Yes
17 Struck By Falling, Shifting Cargo or 27 Guardrail Face
38 Mailbox
brake failure, etc.)
88 Unknown
3rd
4th
Anything Set in Motion by Motor
39 Other Fixed Object (wall,
41 Separation of Units
28 Guardrail End
Vehicle
building, tunnel, etc.)
42 Ran Off Roadway, Right
18
Other
Non
Fixed
Object
43 Ran Off Roadway, Left
44 Cross Median
Vehicle Maneuver Action
Vehicle Defects
Traffic Control Device For
45 Cross Centerline
1 Straight Ahead
13 Stopped in Traffic
This Vehicle
46 Downhill Runaway
3 Turning Left
Roadway Grade
14 Slowing
4 Backing
15 Negotiating a Curve
Roadway Alignment
1 Level
8 Flashing Signal
5 Turning Right
16 Leaving Traffic Lane
12 Suspension
2 Hillcrest
9 Railway Crossing
6 Changing Lanes
1
Straight
17 Entering Traffic Lane
13 Wheels
1 None
3 Uphill
Device
8
Parked
2 Curve Right
77 Other, Explain in
14 Windows/
2
Brakes
4 Downhill
1
No
Controls
10 Person (including
10 Making U Turn
3 Curve Left
Narrative
Windshield
3
Tires
5 Sag (bottom)
4
School
Zone
Sign/
Flagman,
Officer,
11 Overtaking/
88 Unknown
15 Mirrors
4
Lights
(head,
Device
Guard, etc.)
Passing
16 Truck Coupling /
signal,
tail)
5 Traffic Control
13 Warning Sign
9
Ambulance
Trailer Hitch /
14
Intercity
Bus
6
Steering
1
No
Special
Function
Signal
Special Function
77 Other, Explain in
10 Fire Truck
Safety Chains
15 Charter/Tour Bus
7
Wipers
2 Farm Vehicle
6 Stop Sign
Narrative
of Motor Vehicle
11
Farm
Labor
Transport
16 Shuttle Bus
9 Exhaust System 77 Other, Explain in
3 Police
7 Yield Sign
88 Unknown
12 School Bus
Narrative
17 Farm Labor Bus
10 Body, Doors
7 Taxi
13 Transit/ Commuter Bus 88 Unknown
88 Unknown
11 Power Train
8 Military

14

1

14

1

1

1

1

1

1

VIOLATIONS
PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

HSMV 90010 S (V/P) (rev 10/10)
Page ___
8
2 of ___

 REPORTING AGENCY CASE NUMBER

PERSON #

1

1 Driver
2 Non Motorist
3 Passenger

20-033187
VEHICLE #

1

1

PHONE NUMBER

941-204-5323

WILLIE C SHAW
CITY & STATE

1234 17TH ST

1

1A 2B 3C
4 D/Chauffeur
5 E/Operator
6 E/Oper –Rest
7 None

Driver Distracted By

1

1 Not Distracted
2 Electronic Communication
Devices (cell phone, etc.)
3 Other Electronic Device
(navigation device, DVD player)

Driver Vision Obstructions

77

STATE

EXPIRES

S000883473830

FL

10/2025

1 Vision Not Obscured
2 Inclement Weather
3 Parked / Stopped Vehicle
4 Trees / Crops / Bushes

1st

4 Other Inside the Vehicle
(explain in narrative)
5 External Distraction
(outside the vehicle, explain
in narrative)
6 Texting
7 Inattentive
88 Unknown

1 Not Applicable
2 Sleeper Section of Truck Cab
3 Other Enclosed Cargo Area
4 Unenclosed Cargo Area
5 Trailing Unit
6 Riding on Motor Vehicle Exterior (nontrailing unit)
88 Unknown

1st

1

5 Lighting
6 Not Applicable
77 Other, Explain
in Narrative
88 Unknown

ALCOHOL TESTED:
1 Test Not Given
2 Test Refused
3 Test Given
88 Unknown if Tested

SOURCE OF TRANSPORT TO MEDICAL FACILITY
1 Not Transported
2 EMS 3 Law Enforcement
77 Other, Explain in Narrative 88 Unknown

OTHER

1

1

3

1 DOT Compliant
Motorcycle Helmet
2 Other Helmet
3 No Helmet

3

2nd

(ABD)

1 Not Ejected
2 Ejected, Totally
3 Ejected, Partially
4 Not Applicable
88 Unknown

1

5 Deployed-Other
(knee, air belt, etc.)
6 Deployed1 Not Applicable Combination
2 Not Deployed 7 Deployed-Curtain
3 Deployed-Front 88 Deployment
4 Deployed-Side Uknown

2

Scfd

4th

2

Condition At
Time of Crash

5

1 Apparently Normal
3 Asleep or Fatigued
5 Ill (sick) or Fainted
6 Seizure, Epilepsy, Blackout
7 Physically Impaired
8 Emotional (depression,
angry, disturbed, etc.)
9 Under the Influence of
Medications/Drugs/Alcohol
77 Other, Explain in Narrative
88 Unknown

Restraint Systems
(RS)

1 Not Applicable (non-motorist)
2 None Used - Motor Vehicle Occupant
3 Shoulder and Lap Belt Used
4 Shoulder Belt Only Used
5 Lap Belt Only Used
6 Restraint Used - Type Uknown
7 Child Restraint System - Forward Facing
8 Child Restraint System - Read Facing
9 Booster Seat
10 Child Restraint Type Uknown
77 Other, Explain in Narrative

5 Walking/Cycling on Sidewalk
6 In Roadway Other
(working, playing, etc.)
7 Adjacent to Roadway (e.g.,
1 Crossing Roadway
shoulder, median)
2 Waiting to Cross Roadway
8 Going to or from School (K
3 Walking/Cycling Along
12)
Roadway with Traffic (in or
9 Working in Trafficway
adjacent to travel lane)
(incident response)
4 Walking/Cycling Along
10 None
Roadway Against Traffic (in or 77 Other, Explain in Narrative
adjacent to travel lane)
88 Unknown

7 Entering/Exiting Parked/Standing
Vehicle
8 Inattentive (talking, eating, etc)
9 Not Visible (dark clothing, no
lighting, etc.)

ALCOHOL/DRUG/EMS
BAC

3

Action Prior to Crash

8 Sidewalk
9 Median/Crossing Island
10 Driveway Access
11 Shared Use Path or Trail
12 Non Trafficway Area
77 Other, Explain in Narrative
88 Unknown

1 No Improper Action
2 Dart/Dash
3 Failure to Yield Right of Way
4 Failure to Obey Traffic Signs,
Signals, or Officer
5 In Roadway Improperly (standing,
lying, working, playing)
6 Disabled Vehicle Related (working
on, pushing, leaving/approaching)

ALCOHOL TEST TYPE: ALCOHOL
1 Blood
TEST RESULT:
2 Breath
1 Pending
3 Urine
2 Completed
77 Other, Explain in 88 Unknown
Narrative
EMS AGENCY NAME OR ID

1 Yes
2 No
3 Not Applicable

Air Bag Deployed

Ejection (EJECT)

1

3rd

Eye Protection (EP)

Non-Motorist Actions/Circumstances

Safety Equipment

4 Incapacitating
5 Fatal (within 30 days)
6 Non Traffic Fatality

DRIVER OR PASSENGER
Helmet Use (HU)

1 Intersection Marked Crosswalk
2 Intersection Unmarked Crosswalk
3 Intersection –Other
4 Midblock Marked Crosswalk
5 Travel Lane Other Location
6 Bicycle Lane
7 Shoulder/Roadside

1 Pedestrian
2 Other Pedestrian (wheelchair, person
in a building, skater, pedestrian
conveyance, etc.)
3 Bicyclist
4 Other Cyclist
5 Occupant of Motor Vehicle Not in
Transport (parked, etc.)
6 Occupant of a Non Motor Vehicle
Transportation Device
7 Unknown Type of Non Motorist

SUSPECTED
ALCOHOL USE:
1 No
2 Yes
88 Unknown

ROW

26 Ran off Roadway
27 Disregarded other Traffic
Sign
28 Disregarded Other Road
Markings
29 Over Correcting/Over
Steering
30 Swerved or Avoided : Due
to Wind, Slippery Surface, MV,
Object, Non Motorist in
Roadway, etc.
31 Operated MV in Erratic,
Reckless or Aggressive Manner
77 Other Contributing Action

NON-MOTORIST
Non-Motorist Location At Time of Crash

Non-Motorist Description

1 None
2 Helmet
3 Protective Pads Used
(elbows, knees, shins, etc.)
4 Reflective Clothing (jacket,
backpack, etc.)

2nd

9 Smoke
10 Glare
77 All Other, Explain in
Narrative

5 Load on Vehicle
6 Building / Fixed Object
7 Signs / Billboards
8 Fog

1

1 Front
2 Second
3 Third
4 Fourth
77 Other Row
88 Unknown

1 No Contributing Action
2 Operated MV in Careless or
Negligent Manner
3 Failed to Yield Right of Way
4 Improper Backing
6 Improper Turn
10 Followed too Closely
11 Ran Red Light
12 Drove too Fast for Conditions
13 Ran Stop Sign
15 Improper Passing
17 Exceeded Posted Speed
21 Wrong Side of Wrong Way
25 Failed to keepin Proper Lane

77

DRIVER OR PASSENGER
LOCATION: SEAT
Motor Vehicle Seating Position:
(LOC)
Seat
Row
Other
1 Left
2 Middle
3 Right
77 Other
(explain in
narrative)
88 Unknown

INJURY SEVERITY
1 None
2 Possible
3 Non incapacitating

DRIVER
Drivers Actions at Time of Crash

1 Yes
2 No
3 No Req. Endorsement

3

34234

DRIVER LICENSE NUMBER

Required Endorsements

DL Type

5

þ

Check if
Recommend
Driver Re exam
ZIP CODE

SARASOTA, FL

SEX:
1 Male
2 Female
88 Unknown

10/23/1947

24022630

NAME

CURRENT ADDRESS (Number and Street)

DATE OF BIRTH

HSMV CRASH REPORT NUMBER

SUSPECTED
DRUG USE:
1 No
2 Yes
88 Unknown

1

10 Improper Turn/Merge
11 Improper Passing
12 Wrong Way Riding or Walking
77 Other, Explain in Narrative
88 Unknown

DRUG TESTED:
1 Test Not Given
2 Test Refused
3 Test Given
88 Unknown if Tested

DRUG TEST TYPE:
1 Blood
3 Urine
77 Other,
Explain in Narrative

EMS RUN NUMBER

MEDICAL FACILITY TRANSPORTED TO

F20-026950

Sarasota Memorial Hospital

DRUG TEST RESULT:
1 Positive
2 Negative
3 Pending
88 Unknown

ADDITIONAL PASSENGERS
PERSON #

VEHICLE #

DATE OF BIRTH

NAME

CURRENT ADDRESS (Number and Street)

SOURCE OF TRANSPORT TO MEDICAL FACILITY
1 Not Transported
2 EMS 3 Law Enforcement
77 Other, Explain in Narrative 88 Unknown
PERSON #
VEHICLE # NAME

EMS AGENCY NAME OR ID

SOURCE OF TRANSPORT TO MEDICAL FACILITY
1 Not Transported
2 EMS 3 Law Enforcement
77 Other, Explain in Narrative 88 Unknown

HSMV 90010 S (V/P) (rev 10/10)

EMS AGENCY NAME OR ID

SEX LOC: S

R

O

EJECT

HU

CITY & STATE

Page ___
3 of ___
8

ABD

RS

MEDICAL FACILITY TRANSPORTED TO

INJ

SEX LOC: S

R

O

EJECT

HU

CITY & STATE

EMS RUN NUMBER

EP

ZIP CODE

EMS RUN NUMBER

DATE OF BIRTH

CURRENT ADDRESS (Number and Street)

INJ

EP

ABD

ZIP CODE

MEDICAL FACILITY TRANSPORTED TO

RS

 VEHICLE #

2

1 Vehicle in Transport
2 Parked Motor Vehicle
3 Working Vehicle
Hit and Run
YEAR
1 No
2 Yes
88 Unknown
INSURANCE COMPANY (Driver)

2

1

Check if Commercial
VEHICLE LICENSE NUMBER

HRRC67

FL

MAKE

2014

o

STATE

REPORTING AGENCY CASE NUMBER

20-033187

o WDAPF4CC9E9565122

04/2021

STYLE

THMC

43478388

o

2

Towed due
to Damage:
1No 2 Yes

1

CURRENT ADDRESS

GEOFFREY ROBINSON

DAMAGE:
EST. DAMAGE
1 Disabling 4 Minor
2 Functional 88 Unknown
Multicolor
3 None
$3,000
1. Rotation
VEHICLE REMOVED BY
2. Owner Request
3. Driver
77. Other, Explain in Narrative
ZIP CODE
CITY & STATE

COLOR

MH
INSURANCE POLICY NUMBER

NAME OF VEHICLE OWNER (Check if Business)

24022630

REGISTRATION EXPIRES Check if Permanent VIN
Registration

MODEL

PROGRESSIVE AMERICAN INSURANCE
COMPANY

HSMV CRASH REPORT NUMBER

SARASOTA, FL

5824 BEE RIDGE RD 437

34233

TRAILER # LICENSE NUMBER

STATE

REGISTRATION EXPIRES

Check if Permanent VIN
Registration

YEAR

MAKE

LENGTH

AXLES

TRAILER # LICENSE NUMBER

STATE

REGISTRATION EXPIRES

Check if Permanent VIN
Registration

YEAR

MAKE

LENGTH

AXLES

VEHICLE
N
TRAVELING

S

E

W

Off-Road Unknown

ooooþ o

HAZ. MAT. RELEASED
1 No
2 Yes
88 Unknown
MOTOR CARRIER NAME

HAZ. MAT PLACARD
1 No
2 Yes
88 Unknown

ON STREET, ROAD, HIGHWAY

N. Lemon Ave
HAZ. MAT NUMBER

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¡¡

4

Comm/Non-Commercial
1 Interstate Carrier
2 Intrastate Carrier
3 Not in Commerce/Government
4 Not in Commerce/Other Truck

1 Two Way, Not Divided
2 Two Way, Not Divided, with a
Continuous Left Turn Lane
3 Two Way, Divided, Unprotected
(painted >4 feet) Median
4 Two Way, Divided, Positive Median
Barrier
5 One Way Trafficway
88 Unknown
Trailer Type
TRAILER 1 TRAILER 2 1 Single Semi Trailer
2 Tandem Semi Trailer
3 Tank Trailer
4 Saddle Mount/Trailer
5 Boat Trailer
6 Utility Trailer
7 House Trailer

0

2

35

Most Damaged Area
18 Undercarriage 18
19
19
Overturn
20 Windshield 20
21
21
Trailer

¡
PHONE NUMBER

Commercial Motor Vehicle Configuration
1 Vehicle 10,000 lbs or less Placarded
for Hazardous Materials
2 Single Unit Truck (2 axle and GVWR
more than10,000 lbs (4,536 kg))
3 Single Unit Truck (3 or more axles)
4 Truck Pulling Trailer(s)
5 Truck Tractor (bobtail)
6 Truck Tractor/Semi Trailer
7 Truck Tractor/Double Truck
8 Pole Trailer
9 Towed Vehicle
10 Auto Transport
77 Other, Explain in
Narrative
88 Unknown

8 Tractor/Triple
9 Truck more than 10,000 lbs (4,536
kg), Cannot Classify
10 Bus/Large Van (seats for 9 15
occupants, including driver)
11 Bus (seats for more than 15
occupants, including driver)
77 Other, Explain in Narrative
88 Unknown

Cargo Body Type

3 Van/Enclosed Box
4 Hopper
5 Pole Trailer
6 Cargo Tank
1 No Cargo 7 Flatbed
8 Dump
2 Bus
9 Concrete Mixer
1 10,000 lbs (4,536 kg) or less
10 Auto Transport
2 10,001 26,000 lbs (4,536 11,793 kg)
11 Garbage/Refuse
3 More than 26,000 lbs (11,793 kg)
12 Log
4 Not Applicable

Comm

Most Harmful Event

TOTAL LANES

ZIP CODE

Trafficway

15 Low Speed Vehicle
16 (Sport) Utility Vehicle
17 Cargo Van (10,000 lbs
or less)
18 Motor Coach
19 Other Light Trucks (10,000 lbs
or less)
20 Medium / Heavy Trucks (more
than 10,000 lbs (4,536 kg))
21 Farm Labor Vehicle
77 Other, Explain in Narrative
88 Unknown

AT EST. SPEED POSTED SPEED

Area of Initial Impact

CITY & STATE

Vehicle Body Type 13 All Terrain Vehicle (ATV)

1 Passenger Car
2 Passenger Van
3 Pickup
7 Motor Home
8 Bus
11 Motorcycle
12 Moped

HAZ. MAT CLASS

US DOT NUMBER

MOTOR CARRIER ADDRESS

7

o
o

13 Intermodal
Container Chassis
14 Vehicle Towing
Another Vehicle
15 Not Applicable
(vehicle 10,000 lbs
(4,536kg) or less not
displaying HM placard)
77 Other, Explain in
Narrative
88 Unknown

Non Collision
GVWR/GCWR
1 Overturn/Rollover
2 Fire/Explosion
3 Immersion
Collision with Non-Fixed Object
Collision Fixed Object
29 Cable Barrier
Emergency
4 Jackknife
10 Pedestrian
19 Impact Attenuator/Crash Cushion 30 Concrete Traffic Barrier
5 Cargo/Equipment Loss or Shift
Vehicle Use
11 Pedalcycle
31 Other Traffic Barrier
20
Bridge
Overhead
Structure
6 Fell/Jumped From Motor Vehicle
12 Railway Vehicle (train, engine)
32 Tree (standing)
21 Bridge Pier or Support
Sequence of Events
7 Thrown or Falling Object
13 Animal
33 Utility Pole/Light Support
22
Bridge
Rail
8 Ran into Water/ Canal
1st
2nd
14 Motor Vehicle in Transport
34 Traffic Sign Support
23 Culvert
9 Other Non Collision
15 Parked Motor Vehicle
35 Traffic Signal Support
24 Curb
16 Work Zone / Maintenance
36 Other Post, Pole, or Support
[40-46 Sequence of Events only]
25 Ditch
1 No
Equipment
37 Fence
40 Equipment Failure (blown tire,
26 Embankment
2 Yes
17 Struck By Falling, Shifting Cargo or 27 Guardrail Face
38 Mailbox
brake failure, etc.)
88 Unknown
3rd
4th
Anything Set in Motion by Motor
39 Other Fixed Object (wall,
41 Separation of Units
28 Guardrail End
Vehicle
building, tunnel, etc.)
42 Ran Off Roadway, Right
18
Other
Non
Fixed
Object
43 Ran Off Roadway, Left
44 Cross Median
Vehicle Maneuver Action
Vehicle Defects
Traffic Control Device For
45 Cross Centerline
1 Straight Ahead
13 Stopped in Traffic
This Vehicle
46 Downhill Runaway
3 Turning Left
Roadway Grade
14 Slowing
4 Backing
15 Negotiating a Curve
Roadway Alignment
1 Level
8 Flashing Signal
5 Turning Right
16 Leaving Traffic Lane
12 Suspension
2 Hillcrest
9 Railway Crossing
6 Changing Lanes
1
Straight
17 Entering Traffic Lane
13 Wheels
1 None
3 Uphill
Device
8
Parked
2 Curve Right
77 Other, Explain in
14 Windows/
2
Brakes
4 Downhill
1
No
Controls
10 Person (including
10 Making U Turn
3 Curve Left
Narrative
Windshield
3
Tires
5 Sag (bottom)
4
School
Zone
Sign/
Flagman,
Officer,
11 Overtaking/
88 Unknown
15 Mirrors
4
Lights
(head,
Device
Guard, etc.)
Passing
16 Truck Coupling /
signal,
tail)
5 Traffic Control
13 Warning Sign
9
Ambulance
Trailer Hitch /
14
Intercity
Bus
6
Steering
1
No
Special
Function
Signal
Special Function
77 Other, Explain in
10 Fire Truck
Safety Chains
15 Charter/Tour Bus
7
Wipers
2 Farm Vehicle
6 Stop Sign
Narrative
of Motor Vehicle
11
Farm
Labor
Transport
16 Shuttle Bus
9 Exhaust System 77 Other, Explain in
3 Police
7 Yield Sign
88 Unknown
12 School Bus
Narrative
17 Farm Labor Bus
10 Body, Doors
7 Taxi
13 Transit/ Commuter Bus 88 Unknown
88 Unknown
11 Power Train
8 Military

15

1

15

1

8

1

1

1

1

VIOLATIONS
PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

HSMV 90010 S (V/P) (rev 10/10)
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8
4 of ___

 NARRATIVE

REPORTING AGENCY CASE NUMBER

HSMV CRASH REPORT NUMBER

24022630

20-033187

On 06/01/2020 at approximately 1724 hours, I was dispatched to the area of 10th Street and N.
Lemon Ave in reference to a vehicle crash. Upon arrival I observed a silver Cadillac (FL tag
JLWF40) on the sidewalk located on the west side of the road. The vehicle had front driver and
passenger side damage.
When I made contact with the vehicle, I observed Tom Barwin in the rear of the vehicle behind
the driver (Willie Shaw). Rescue was on scene and was assisting Shaw out of the vehicle for
medical assessment. Rescue advised they were going to be transporting Shaw to Sarasota
Memorial Hospital (SMH) for medical treatment. Officer Torres was on scene and had Upman’s
towing respond to remove Shaw’s vehicle because it was inoperable due to the damage it
sustained from the incident.
While gathering witnesses I was approached by Geoffrey Robinson who advised that Shaw’s
vehicle had impacted his RV (FL tag HRRC67) on the rear driver side. Robinson stated that he did
not witness the incident and was not in the RV while the incident took place. Robinson stated
that a friend had notified him that someone hit his RV with their car. Robinson advised he was
not inside of the RV when the incident occurred, but the RV sustained heavy damage to the rear
driver side. A partial piece of the RV was imbedded into the front driver side of the Cadillac.
Before leaving the scene, I have provided Robinson with a driver’s exchange and a case number
regarding the incident.
After speaking with Robinson, I was approached by Claire Boren who stated she had witnessed
the incident. Boren advised that she observed the Cadillac traveling NB on N. Lemon Ave
swerving and traveling in the east lane, hitting another vehicle. Boren advised that she had to get
out of the way because she thought the vehicle was going hit her. Boren then advised the
Cadillac traveled through the intersection of N. Lemon Ave and 6th Street. Boren explained after
passing through the intersection the Cadillac drove over the median traveling NB in the SB lanes
of N. Lemon Ave. Boren stated that is when the Cadillac side swiped the RV. Boren then advised

ADDITIONAL PASSENGERS
PERSON #

VEHICLE #

DATE OF BIRTH

NAME

EMS AGENCY NAME OR ID

R

O

EJECT

HU

EP

DATE OF BIRTH

EMS RUN NUMBER

RS

MEDICAL FACILITY TRANSPORTED TO

INJ

SEX LOC: S

R

O

EJECT

HU

EP

CITY & STATE

EMS AGENCY NAME OR ID

ABD

ZIP CODE

EMS RUN NUMBER

CURRENT ADDRESS (Number and Street)

SOURCE OF TRANSPORT TO MEDICAL FACILITY
1 Not Transported
2 EMS 3 Law Enforcement
77 Other, Explain in Narrative 88 Unknown

SEX LOC: S

CITY & STATE

CURRENT ADDRESS (Number and Street)

SOURCE OF TRANSPORT TO MEDICAL FACILITY
1 Not Transported
2 EMS 3 Law Enforcement
77 Other, Explain in Narrative 88 Unknown
PERSON #
VEHICLE # NAME

INJ

ABD

RS

ZIP CODE

MEDICAL FACILITY TRANSPORTED TO

ADDITIONAL VIOLATIONS
PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

REPORTING OFFICER
ID/BADGE NUMBER RANK & NAME

DEPARTMENT

1792

Sarasota Police Dept

OFC. R Howell

HSMV 90010 S (N/D) (rev 10/10)

Page ___
5 of ___
8

FHP

SO

PD OTHER

ooþ

 NARRATIVE

REPORTING AGENCY CASE NUMBER

HSMV CRASH REPORT NUMBER

24022630

20-033187

the Cadillac continued traveling NB until crashing on the sidewalk just south of the intersection
of N. Lemon and 10th Street.
I then located Paul Jeanot who stated he witnessed the incident also. Jeanot advised he observed
the Cadillac run over the median just after passing through the intersection of Blvd of the Arts
and N. Lemon Ave. Jeanot advised the Cadillac impacted the rear driver side of the RV that was
parked on the east N. Lemon Ave in the 700 block. Jeanot stated that the Cadillac kept traveling
NB in the SB lanes until it crashed just south of the intersection of 10th Street and N. Lemon Ave.
I spoke with Tom Barwin via phone to gather his recollection of the incident. Barwin advised that
he was parked on the east side of the road, in front of 710 N. Lemon Ave to use his phone when
he noticed a silver Cadillac driving erratically and cross into the opposite lanes of traffic. Barwin
stated he observed the vehicle crash and he immediately called 911 to have help respond. Barwin
stated when he approached the vehicle, he saw that Shaw was the driver and knew that he had
pre-existing health issues, so he got in the car to check his pulse and render the necessary aid
until rescue arrived.
After speaking with all of the witnesses I responded the SMH to check on Shaw’s health status
and speak with him about the incident if his health permitted. When I made contact with Shaw,
he was cognitive, so I began inquiring about the incident. Shaw advised he was leaving City Hall
located at 1565 1st Street. Shaw stated after leaving City Hall he did not remember anything
regarding the crash. He advised the next thing he remembered was speaking with rescue
personnel after being assisted from his vehicle. I asked Shaw if he had any medical conditions
that might have caused him to go into a blank state. Shaw state that he had a recent medical
episode approximately 2 months prior to this incident. Shaw also advised he has a pacemaker in
place. Medical staff couldn’t advise Shaw’s health issues while I was at SMH, they stated they
were still running multiple tests to pinpoint the issue. While at SMH I provided Shaw’s daughter
with the driver’s exchange and a business card with the case number on it regarding the incident.

ADDITIONAL PASSENGERS
PERSON #

VEHICLE #

DATE OF BIRTH

NAME

EMS AGENCY NAME OR ID

R

O

EJECT

HU

EP

DATE OF BIRTH

EMS RUN NUMBER

RS

MEDICAL FACILITY TRANSPORTED TO

INJ

SEX LOC: S

R

O

EJECT

HU

EP

CITY & STATE

EMS AGENCY NAME OR ID

ABD

ZIP CODE

EMS RUN NUMBER

CURRENT ADDRESS (Number and Street)

SOURCE OF TRANSPORT TO MEDICAL FACILITY
1 Not Transported
2 EMS 3 Law Enforcement
77 Other, Explain in Narrative 88 Unknown

SEX LOC: S

CITY & STATE

CURRENT ADDRESS (Number and Street)

SOURCE OF TRANSPORT TO MEDICAL FACILITY
1 Not Transported
2 EMS 3 Law Enforcement
77 Other, Explain in Narrative 88 Unknown
PERSON #
VEHICLE # NAME

INJ

ABD

RS

ZIP CODE

MEDICAL FACILITY TRANSPORTED TO

ADDITIONAL VIOLATIONS
PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

REPORTING OFFICER
ID/BADGE NUMBER RANK & NAME

DEPARTMENT

1792

Sarasota Police Dept

OFC. R Howell

HSMV 90010 S (N/D) (rev 10/10)

Page ___
6 of ___
8

FHP

SO

PD OTHER

ooþ

 NARRATIVE

REPORTING AGENCY CASE NUMBER

HSMV CRASH REPORT NUMBER

24022630

20-033187

Based on the statements made from all parties I have determined Willie Shaw is at fault for the
incident, but I believe Shaw’s health condition was the main cause of the crash. Because the
reason for the crash is health related and unavoidable, I have not issued Shaw a citation. No
further action.

ADDITIONAL PASSENGERS
PERSON #

VEHICLE #

DATE OF BIRTH

NAME

EMS AGENCY NAME OR ID

R

O

EJECT

HU

EP

DATE OF BIRTH

EMS RUN NUMBER

RS

MEDICAL FACILITY TRANSPORTED TO

INJ

SEX LOC: S

R

O

EJECT

HU

EP

CITY & STATE

EMS AGENCY NAME OR ID

ABD

ZIP CODE

EMS RUN NUMBER

CURRENT ADDRESS (Number and Street)

SOURCE OF TRANSPORT TO MEDICAL FACILITY
1 Not Transported
2 EMS 3 Law Enforcement
77 Other, Explain in Narrative 88 Unknown

SEX LOC: S

CITY & STATE

CURRENT ADDRESS (Number and Street)

SOURCE OF TRANSPORT TO MEDICAL FACILITY
1 Not Transported
2 EMS 3 Law Enforcement
77 Other, Explain in Narrative 88 Unknown
PERSON #
VEHICLE # NAME

INJ

ABD

RS

ZIP CODE

MEDICAL FACILITY TRANSPORTED TO

ADDITIONAL VIOLATIONS
PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

REPORTING OFFICER
ID/BADGE NUMBER RANK & NAME

DEPARTMENT

1792

Sarasota Police Dept

OFC. R Howell

HSMV 90010 S (N/D) (rev 10/10)

Page ___
7 of ___
8

FHP

SO

PD OTHER

ooþ

     
     
    
 

Legend
(11w: White Car
Brown the Parts

N- Lemnn Ave

33'
3
3

Page A of A