FLORIDA TRAFFIC CRASH REPORT LONG FORM MAIL TO DEPT. HIGHWAY SAFETY 8: MOTOR VEHICLES, TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING, TALLAHASSEE, FL 32399-0537 TIME LOCATION DO NOT WRITE IN THIS SPACE Date ot Crash Time ot Crash Time Otticer Notitied Time Otlicer Arrived Invest. Agency Report Number HSMV Crash Report Number 29!Oct/2010 0980636670 County Code)' City Code Feet or Mi|e(s) Direction ot City or Town (check it in City County 12 oo 5 GROVELAND or Town) Lake At Node No. or Feet or Mi|e(s) From Node No. Next Node No. No. ot Lanes 1:1 1. Divided On Street, Road or Highway 2 2. Undivided SR 33 At The Intersection 01 (street, road or highway) or Feet or Mi|e(s) Direction From Intersection 01 (street, road or highway) 200 GROVELAND AIRPORT RD SECTION 1 Pedestrian Vehicle Driver 1 . Phantom Year Make Type Use Veh. License Number State Vehicle Identitication Number 03. undgmanigge ACTION 2. Hit and Run 2007 FORD 03 01 K014RO FL 3- WA Q9. Windsheild Trailer Or Towed Vehicle Trailer Type 21. Trailer Intormation Vehicle Traveling on At Est. MPH Posted Speed Est. Vehicle Damage 1. Disabling 1:1 Est. Trailer Damage Show tirst point ot 3 CR 33 60 55 $15,000 2. Functional Vehicle damage and 3_ N0 Damage circle damaged areas Motor Vehicle Insurance Company (Liability or PIP) Policy Number Vehicle Removed By: 1. Tow Rotation List 3. Driver PROGRESSIVE 201911517 REVIS 2. Tow Owner's Request 4. Other Name ot Vehicle Owner (Check Box It Same As Driver) 1:1 Current Address (Number and Street) City and State Zip Code GLENN KISH 12528 SUGARWOOD LN CLERMONT FL 34715 Name ot Owner (Trailer or Towed Vehicle) Current Address (Number and Street) City and State Zip Code Name of Motor Carrier (Commercial vehicle only) Current Address (Number and Street) City, State and Zip Code US DOT or ICC MC Identitication Numbers Name of Driver (Taken trom Driver |icense);' Pedestrian Current Address (Number and Street) City, State and Zip Code Date 01 Birth LEIGHTON KISH 12528 SUGARWOOD LANE CLERMONT FL 34715 09!Nov.l1989 Driver License Number State DL Re . A|CfDrug Test Type El Results Alc;'Drug Phys.Det Res. Race Sex In]. S. Equip. Eject. En 1 B|00d 3 Urine 5 None Breath 4 Retused Hazardous Materials 1Z1 Placarded It Yes, Indicate Name or 4 Digit Number From diamond Box Was Hazardous Recommend Driver Driver's Phone No. Being Transported 1 yes 2 No on Placard, and 1 Digit Number From Bottom of Diamond Material Spilled? it Yes Explain In Narrative 1yes2No 1yes2No 1yes2No SECTION Pedestrian Vehicle Driver 1 . Phantom 11 Year Make Type Use Veh. License Number State Vehicle Identitication Number ACHOTI 2. Hit and Run 3. NEA Trailer Or Towed Vehicle Trailer Type Intormation Vehicle Traveling on At Est. MPH Posted Speed Est. Vehicle Damage 1. Disabling 1:1 Est. Trailer Damage Show tirst point ot 1:1 2_ Func1i0na| vehicle damage and 3_ N0 Damage circle damaged areas Motor Vehicle Insurance Company (Liability or PIP) Policy Number Vehicle Removed By: 1. Tow Rotation List 3. Driver 2. Tow Owner's Request 4. Other Name of Vehicle Owner (Check Box It Same As Driver) Current Address (Number and Street) City and State Zip Code Name of Owner (Trailer or Towed Vehicle) Current Address (Number and Street) City and State Zip Code Name of Motor Carrier (Commercial vehicle only) Current Address (Number and Street) City, State and Zip Code US DOT or ICC MC Identitication Numbers Name of Driver (Taken trom Driver |icense)1' Pedestrian Current Address (Number and Street) City, State and Zip Code Date Ot Birth Driver License Number State DL Re . A|CfDrug Test Type Results A|c1'Drug Phys.Det Res. Race Sex In]. S. Equip. Eject. Type 1 Blood 3 Urine 5 None I 2 Breath 4 Retused Hazardous Materials 1: Placarded It Yes, Indicate Name or 4 Digit Number From diamond Box Was Hazardous 1:1 Recommend Driver Re--exam, Driver's Phone No_ Being Transported 1 yes 2 No on Placard, and 1 Digit Number From Bottom ot Diamond Material Spilled'? it Yes Explain In Narrative 1yes2No 1yes2No 1yes2No CODE INFORMATION Page 1 ot 4 Vehicle Type Vehicle Use Trailer Type Residence I-'hysical Detects A|coho|fDruq Use |1 Locati_on In 01 Automobile 01 Private Transportation 01 Single Semi Trailer 1 00111111, 01013511 1 NO Known 1 Not Drinking or using Drugs Vehicle 02 Van 02 Commercial Passengers 02 Tandem Semi Trailer 2 111 31319 2 E1,eS1g111 1391901 2 Alcohol -- Under lntluence 1 1:1-0111 L911 1.1196? or 4 rear 0: Cargo 11:1 3 N011_1:1eS1de111 0111 O13151119 3 1:a11g11e7AS1eep iglrugrs gnsler 2 1:1-0111 Came,- 0 ic rans ortation 0 a ount at - co rugs -- er - 04 Medium Truck -- 4 rear tires o5 Public SchooI:l) Bus 05 Boat Trailer 4 Foragn 5 Unknown EI $2229 DBIBCT . . 3, Truck -- 2 or more rear 06 KrivEit1e School Bus 06 1U1tility I UL IYDB I I Race 6 81311211113' Ep11epSy' 2 T981 5 1;1ea1,Qen1e1, -1 K-1 b_B -1 07 37709 White Other Detect 1:1 1 6 Rear Right 06 rado" 5' 08 Law Entorcemem 08 4 DfChautteur 2 Black 93" '3 7 In Bod Ot Truck o? Motor Home (RV) 09 1:11e,rp1eSc11e 09 -rowed 119111019 5 E10 1 3 H. . Injury Severity 11 1111111111811 11 Se 8 BUS Pgssenger 08 Bus (driver seats tor 9-15) 10 1111111151111 10 A1110 --11.a11Sp01.1 0" 1 None 1 1_ 9 Omar 09 Bus (driver seats for over 15) 11 0111 1 77 0111 6 4 Oihel . 0 U59 10 Bicycle 12 11111131, Ovemmen er None 3 121Seat 1 |:1e1;1ed 11 13 1 1111- . . 3''ll_935 12 Moped 14 HBCIUITBCI I 5393' 4 3 Child Restraint :0 13 All Terrain Vehicle 15 Car 0 11811 Endorsements 1 1115113 5 Fatal iwnnin 30 days) 4 Air Bag -- Deployed 95. 14 Train 77 011131. 1 Yes 2 1:e111a1e 5 5 Air bag -- Not Deployed 3 ParI'aI 15 Low Speed Vehicle 2 N0 6 Sattey Helmet Other 3 NO e1,1dOrSeme111 7 Protection Required SECTION Pedestrian Vehicle Narrative) 03 Failure to Yield Right--Ot--Way 04 Improper Backing 05 Improper Lane Change 08 Improper Turn 0? Alcohol -- Under Intluence 08 Drugs -- Under Intluence 10 Followed To Closely 11 Disrecarded Trattic Signal 12 Exceeded Sate Speed Limit 13 Disregarded Stop Sign 15 Improper Passing 18 Drove Lett ot Center 1? Exceeded Stated Speed Limit 18 Obstructing Trattic 09 Alcohol Drugs -- Under Intluence 14 Failed To Maintain Equip.( Vehicle 03 Warn! Smooth Tires 04 Detective! Improper Lights 05 PuncturefBIowout 06 Steering Mech. 0? Windshield Wipers 08 EquipmentfVehicIe Detect All Other (Explain In Narrativelniproper Load 1point or Collision 20 Disregarded other 03 Making Letl Turn 04 Backing 05 Making Right Turn 08 Changing Lanes 0? Entering(Leaving( Parking Space Runaway DD Driver 1 . Phantom lj Year Make Type Use Veh. License Number State Vehicle Identitication Number 2. Hit and Run 3. WA Trailer Or Towed Vehicle Trailer Type Intormation Vehicle Traveling on At Est. MPH Posted Speed Est. Vehicle Damage 1. Disabling Est. Trailer Damage Show tirst point ot El 2_ FL1nc110na| vehicle damage and 3_ N0 Damage circle damaged areas Motor Vehicle Insurance Company (Liability or PIP) Policy Number Vehicle Removed By: 1. Tow Rotation List 3. Driver El 2. Tow Owner's Request 4. Other Name ot Vehicle Owner (Check Box It Same As Driver) Current Address (Number and Street) City and State Zip Code Name ot Owner (Trailer or Towed Vehicle) Current Address (Number and Street) City and State Zip Code Name ot Motor Carrier (Commercial vehicle only) Current Address (Number and Street) City, State and Zip Code US DOT or ICC MC Identitication Numbers Name ot Driver (Taken trom Driver |icense)( Pedestrian Current Address (Number and Street) City, State and Zip Code Date Ot Birth Driver License Number State DL Re . A|C(Drug Test Type Results Alcl-"Drug Phys.De1 Res. Race Sex In]. S. Equip. Eject. Type 1 Blood 3 Urine 5 None I 2 Breath 4 Retused Hazardous Materials Placarded It Yes, Indicate Name or 4 Digit Number From diamond Box I: Was Hazardous Recommend Driver Re-exam, Driver's Phone No. Being Transported 1 yes 2 N0 on Placard, and 1 Digit Number From Bottom ot Diamond Material Spilled'? it Yes Explain In Narrative 1yes2No 1 yes2 No 1yes2No Property Damaged -- Other Than Vehicles Est. Amount Owner's Name Address City State Zip 1 ROAD SIGN $100 STATE DOT 1405 THOMAS AVE LEESBURG FL 34748 Property Damaged -- Other Than Vehicles Est. Amount Owner's Name Address City State Zip 2 GUARD RAIL $5,000 STATE DOT 1405 THOMAS AVE LEESBURG FL 34748 |Contributing Causes - Driver(Pedestrian |1vehiole Detect 1|Venicle Movement 1 [Vehicle Special Functions 01 No Improper Driving(Action 01 13 1 1 01 Straight Ahead 1 None 02 Careless Driving (Explain in 02 13:1 S1-gfiesg O2 Slowing! Stopping! Stalled 2 Farm 3 Police Pursuit 4 Recreational 5 Emergency Operation 12 Driverless or 8 Construction(Maintenance DD [Source Ot Carrier Intormation 08 Properly Parked Vehicle 1 1,91 1' 131 v39 Other 2 0 a ing - urn xpa_in in - - it tarratvei 33:25? DD . 01 On Road 04 Median Tram Comm 02 Not On Road 05 Turn Lane 21 Driving Wrong Sidemay 03 Shoulder 22 Fleeing Police 23 Vehicle Moditied [Work Area 24 Driver Distraction 01 None (Explain in Narrative) 02 Nearby All Other (Explain in 03 Emered Narrative) DD 08 Working on Vehicle in Road |Pedestrian Action ||Location Type 01 Crossing Not At Intersection 0? Working in Road 1 2 3 1 Primarily 02 Crossing At Mid--bIock Crosswalk 08 Standing(PIaying BUSIPBSS 03 Crossing At Intersection in Road El 2 o4 Walking Along Road With Trattic os Standing in Peeidential 05 Walking Along Road Against Pedefiirlail ISIEWI 3 0139" Trattic COUIWY All Other (Explain in Narrative) 88 Unknown |First (Subsequent Harmtul Event |Road System Identitier |Lighting Condition 08 Collision With Parked Car 09 Collision with MV on Roadway 10 Collision With Pedestrian 01 Collision With MV in Transport (Rear End) 02 Collision With MV in Transport (Head On) 03 Collision With MV in Transport (Angle) 04 Collision With MV in Transport (Lett Turn) 05 Collision With MV in Transport (Right Turn) 06 Collision With MV in Transport (Sideswipe) 0? Collision With MV in Transport (Backed Into) 15 Collision With Animal 18 MV Hit Sign I Sign Post 1? MV Utility Pole! Light Pole 18 MV Hit Guardrail 19 MV Hit Fence 20 MV Hit Concrete Barrier Wall 21 MV Hit BridgefPier(Abutment(RaiI 33 T_raotor(Traller 22 MV Hit Tree(Shrubbery 34 Fire 23 Collision With Construction 35 Explosion 28 Collision With Moveable Object on Road 29 Mv Ran Into Ditch(CuIvert 30 Ran Ott Road Into Water 31 Overturned 32 Occupant Fell From Vehicle DE DE EDD 01 Interstate 02 U.S. 03 State 04 County 05 Local 0? Forest Road 01 D3 11 111 08 Private 02 Dugkg Roadway 03 Dawn 04D St tL ht &ExpIa1n In 3" I "99 I arrative) 08 Turnpike I Toll 05 Dark (No Street Light) 88 Unknown Road Surtace weather Condition Road Surtace Type Barricade Sign 38 Downhill Runaway |j 01 Dry 01 c1ea1- 01 SIag(GraveI(Stone 11 Collision With Bicycle 24 Collision With Trattic Gate 3? Cargo Loss or Shitt 02 W61 02 Cmudy 02 12 Collision With Bicycle (Bike Lane) 25 Collision With Crash Attenuators 38 Separation ot Units 03 Slippery 03 Ram 03 13CoIIision With Moped 28 Collision With Fixed Object Above 39 Median Crossover Collision With Train Rfififliv Ob fl? All Other (Explain in All other Omar 05 D11-1 27 '1 I a"a""9I "Explain ip (Explain i)n Other)(ExpIain arrative arrative in arrative |Road Condtions At Time Ot Crash 1Vision Obstructed [Traffic Control [Site Location |Tra'rIicway Character o1 No Detects o1 Vision Not Obstructed o1 No Control NOW ol Straight--LeveI 02 Obstruction With Warning 02 Inclement Weather 02 Special Speed Zone 02 A1 lmersecmn 02 Straight- 03 Obstruction Without Warning 03 Parkedl' Stopped Vehicle 03 Speed Control Sign 12 03 Upgrade(Downgrade 04 Road under Repairf Construction 04 Trees(Crops(Bushes 04 School Zone 04 03 Curve -- Level 05 Loose Surtace Materials 05 Load On Vehicle 05 Trattic Signal Z0119 '35 Fialiroad 04 Curve -- oo Shoulders - So1t(Low(High oo BuiIding(Fixed Object oo Stop sign 3 A11 Q1119, 06 Bridge to Parking Lot - Private Uporade(Downgrade or HoIes(Ruts(Unsate Paved Edge or Signs(BiIIboards 07 Yield Sign (Explain In 0? Edlradda Flame 11 Private Property We Shoulder 08 Standing Water 08 Fog 08 Flashing Light al'l'allV9) 08 Ex" FIEIWP 12 300") 09 Worn(PoIished Road Surtace 09 Smoke 09 Railroad Signal 09 PBFKIPQ L01 - PUDIIC PUDIIC BUS SIOPZOIIG 01 Paved El ?7 All other (Explain In Narrative) 10 Glare El 10 Otticer(Guard(FIagperson|E| 771?)" Qiher IEXPIEWI 02 Unpaved All other (Explain In Narrative) 11 Posted No U--Turn Na"a""'9i 03 curb Vlolatc-r(s) Section Name 01 Violator FL Statute Number Charge Citation Number 1 LEIGHTON KISH 316.1925.1 CARELESS DRIVING 2098-SSA Section Name O1 Violator FL Statute Number Charge Citation Number Section Name 01 Violator FL Statute Number Charge Citation Number Section Name 01 Violator FL Statute Number Charge Citation Number Page 2 o1 4 FLORIDA TRAFFIC CRASH REPORT Do NOT wan-E nu 1-HIS NARRATIVEIDIAGRAM MAIL TO DEPT. HIGHWAY SAFETY 8: MOTOR VEHICLES, TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING, TALLAHASSEE, FL 32399-0537 Time EMS Notitied (Fatalities Only) Time EMS Arrived (Fatalities Only) Date Ot Crash County' City Code Invest. Agency Report Number HSMV Crash Report Number 29!Oct!2010 12 00 80636670 (Narrative) Vehicle-1 was traveling south on State Road 33, north of Groveland Airport Road. Vehicle-1 entered the west shoulder. The right side of Vehicle-1 struck a road sign on the west shoulder. Vehicle-1 continued southbound on the west shoulder. The right front of Vehicle-1 struck a guard rail. The vehicle came to rest in contact with the guard rail. Vehicle-1 left 133 feet of furrows on the west shoulder rotating counter clockwise. Vehicle-1 took out 25 feet of guard rail after impact.-NOTE- The guard rail punctured the fire wall of the vehicle and entered the passenger compartment. There was an odor of an alcoholic beverage in the vehicle. The Driver stated he had consumed a half of an alcoholic beverage prior to driving. There was an odor of alcohol about the Drivers person but I could not determine if it was coming from his breath or his clothes. The Driver stated Passenger-1 had an alcoholic beverage in his hand at the time of the crash and it spilled in the vehicle. I read the Driver his Miranda warning and asked if he would perform FSE's and he consented. The Driver's performance of FSE's did not indicate any level of First Contributing Cause 02 Careless Driving. Vehicle-1 Driver failed to maintain control of the vehicle at all times and failed to drive within that portion of the roadway designated for vehicular traffic. Latitude: 28.536525 Longitude: -81.8514983333333 Sec# Pass# Passenger's Name Current Address City State Zip Code Date Of Birth Race Sex Loc Inj S. Eqip_ Eject 1 01 CHARLES PIKE REDS LN CL ERMONT FL 34711 19!Jan.r1989 1 1 3 4 2 1 Sec# Pass# Passenger's Name Current Address City State Zip Code Date Of Birth Race Sex Loc Inj S. Eqip_ Eject 1 02 JASMINE WOODCOCK 2550 cjnus TOWER BLVD 3202 CL FL 34711 19/Aug.l1993 1 2 6 2 1 1 Sec# Pass# Passenger's Name Current Address City State Zip Code Date Of Birth Race Sex Loc Inj S. Eqip_ Eject I Sec# Pass# Passenger's Name Current Address City State Zip Code Date Of Birth Race Sex Loc Inj S. Eqip_ Eject I Sec# Pass# Passenger's Name Current Address City State Zip Code Date Of Birth Race Sex Loc Inj S. Eqip_ Eject I Sec# Pass# Passenger's Name Current Address City State Zip Code Date Of Birth Race Sex Loc Inj S. Eqip_ Eject I VIo|ator(s) Section Name 01 Violator FL Statute Number Charge Citation Number Section Name Ot Violator FL Statute Number Charge Citation Number Witness Name Current Address City State Zip Code Witness Name Current Address City State Zip Code First Aid Given By -- Name 1 Physicals Or Nurse 4 Certified 1s1Aider Injured Taken To: By -- Name GROVELAND F. D. 3 PaV_am91'C_ 01 EMT 5 other O.R.M.C. AIR CARE 3 Police Otticer Was 1 Yes It No, Then Where? Is Investi ation 1 If No, Then Why? Date of Report Photos 1 Yes 2 If Yes, By Whom? Investi ation 2 No I3 Complete. 2g,roc1,r2o1o Taken? 2 No 1 Agency Made tScene? 1 Yes 2 No 2 Other Investigator -- Rank Signature |D;'Badge Number Department 80 CPD Other TPR J. A. RATLIFF 2133 FHPD El Page 3 of 4 NOT TB LE Guard Rail State 33 Warning Sign Page 4 014