Page of 7 Number of Motor Vehicles: Automobiles, Motorcycles, etc. Number of Non-Motorists: Pedestrians, Bicyclists, etc. Form PR- REV July 24. Crash Summary (Front) 22-060536 Date of Crash (YYYYMMDD) 2 0 3 0 0 Latitude 4.545094 Longitude -73.048524 For all numeric fields: = 'Unknown' TRAFFICWAY OWNERSHIP. Public Road 02. Private Road TRAFFICWAY CLASS. Trafficway, On Road 02. Trafficway, Not on Road. Non-Trafficway 04. Parking Lot LIGHT CONDITIONS. Daylight 02. Dawn. Dusk 04. Dark- Lighted 05. Dark- Not Lighted 06. Dark Unknown Lighting Time (-2359) 2 0 6 CRASH DATE, TIME, SEVERITY, AND LOCATION Town Name Town # Waterbury Crash occurred on (street name or route #) at its intersection with (street name or route #) Congress Ave. If not at an intersection: WEATHER CONDITIONS (choose up to 2). Clear 02. Cloudy. Fog, Smog, Smoke 04. Rain 05. Sleet or Hail 06. Freezing Rain/Drizzle 07. Snow 08. Blowing Snow 09. Severe Crosswinds 0. Blowing Sand, Soil, Dirt TRAFFICWAY SURFACE CONDITIONS. Dry 02. Wet. Snow 04. Slush 05. Ice/Frost 06. Moving Water 07. Sand 08. Mud, Dirt, Gravel 09. Oil 0. Standing Water For all numeric fields: = 'Unknown' WORK ZONE. No distance TYPE OF INTERSECTION. Not an Intersection 02. Four-Way Intersection. T-Intersection 04. Y-Intersection 05. L-Intersection 06. Traffic Circle 07. Roundabout 08. Five-Point, or More Feet Tenths of Mile N, S, E, W at of James St. CRASH FACTORS AND CONDITIONS LOCATION OF FIRST HARMFUL EVENT FIRST HARMFUL EVENT. On Roadway 02. Shoulder Non-Collision:. Median. Overturn/Rollover 04. Roadside 02. Fire / Explosion 05. Gore. Immersion, Full or Partial 06. Separator 04. Jackknife 05. Cargo/Equipment Loss or Shift 07. In Parking Lane or Zone 06. Fell/Jumped from Vehicle 08. Off-Roadway Location Unknown 07. Thrown or Falling Object 09. Outside Right-of-Way (trafficway) 08. Other Non-Collision CRASH-SPECIFIC LOCATION. Non-Junction 02. Intersection. Intersection-Related 04. Entrance / Exit Ramp 05. Entrance / Exit Ramp-Related 06. Railway Grade Crossing 07. Crossover-Related 08. Driveway Access 09. Driveway Access-Related 0. Shared-Use Path or Trail. Through Roadway 2. Acceleration / Deceleration Lane 3. On A Bridge 4. HOV Lane 5. Service or Rest Area 6. Weigh Station 7. Other Location Not Listed Above Within an Interchange Area (median, shoulder and roadside) 02 SCHOOL BUS RELATED. No, a school bus was directly involved. Yes, a school bus was indirectly involved LOCATION. Before the First Work Zone Warning Sign 02. Advance Warning Area. Transition Area 04. Activity Area 05. Termination Area 5 Crash Severity Fatal Injury PDO name of nearest intersecting road, town line, or mile marker Collision with Person, Vehicle, or Non-Fixed Object: 09. Pedestrian 0. Pedal cycle/pedal-cyclist. Other Non-motorist 2. Railway Vehicle (train, engine) 40. Deer 3. Animal Other Than Deer (live) 4. Motor Vehicle in Operation 5. Parked Motor Vehicle 6. Struck by Falling, Shifting Cargo or Anything Set in Motion by Motor Vehicle 7. Work Zone/Maintenance Equipment 8. Other Non-Fixed Object Collision With Fixed Object: 9. Impact Attenuator/Crash Cushion 20. Bridge Overhead Structure 2. Bridge Pier or Support 22. Bridge Rail 23. Cable Barrier 24. Culvert 25. Curb 26. Ditch 27. Embankment 28. Guardrail Face 29. Guardrail End 30. Concrete Traffic Barrier 3. Other Traffic Barrier 32. Tree (standing) 33. Utility Pole/Light Support 34. Traffic Sign Support 35. Traffic Signal Support 36. Fence 37. Mailbox 38. Other Post, Pole or Support 39. Other Fixed Object (wall, building, tunnel, etc.) WORK ZONE CRASH INFORMATION TYPE. Lane Closure 02. Lane Shift / Crossover. Work on Shoulder or Median 04. Intermittent or Moving Work MANNER OF IMPACT (Applies to: multi-vehicle crashes) 09. Front to Rear 02. Front to Front. Angle 04. Sideswipe, Same Direction 05. Sideswipe, Opposite Direction 06. Rear to Side 07. Rear to Rear WORKERS PRESENT. No CONTRIBUTING CIRCUMSTANCES, ENVIRONMENTAL (choose up to 3). Weather Conditions 02. Visual Obstruction(s). Glare 04. Animal(s) in Roadway CONTRIBUTING CIRCUMSTANCES, ROAD (choose up to 3). Backup Due to Prior Crash 02. Backup Due to Prior Non-recurring Incident. Backup Due to Regular Congestion 04. Toll Booth/Plaza Related 05. Road Surface Condition (wet, icy, snow, slush, etc.) 06. Debris 07. Ruts, Holes, Bumps 08. Work Zone (construction/ maintenance/utility) 09. Worn, Travel-Polished Surface 0. Obstruction in Roadway. Traffic Control Device Inoperative, Missing, or Obscured 2. Shoulder (none, low, soft, high) 3. Non-Highway Work Complete all for crashes occurring in a Work Zone ENFORCEMENT PRESENT. No
Page 2 of 7 Form PR- REV July 24. Crash Summary (Back) DIAGRAM 22-060536 Vehicles were moved prior to police arrival NARRATIVE Officers Narrative: Describe any unusual circumstances associated with the crash, including officer's observations. Refer to each by motor vehicle number and/or non-motorist number Congress Ave is a straight, 2 lane roadway divided by a double yellow line. There weather was clear, Dry, and Daylight with no other adverse road conditions at the time of this accident. Pedestrian, Paula Harvey, stated that while she was walking in the public roadway, eastbound, on Congress Ave, when at the T-intersection of James St., she was struck from behind by a black four door sedan. Harvey stated that she was launched in the air several feet and landed on her right side. Harvey complained of right leg and right shoulder pain. Harvey stated that she did not see the make, model, or license plate of the striking vehicle, which fled eastbound on Congress Ave. The occupants of TU are unknown. Harvey stated she was not on her phone or listening to music. AMR Ambulance and Waterbury Fire Department responded to the scene. Harvey, who was limping, refused medical attention. A pick-up was placed out to area cars with the striking vehicle s description. I was unable to locate the striking vehicle in the immediate surrounding areas. At this time there are no further leads or witnesses to the incident. Based on my investigation at the scene I found that Pedestrian, Paula Harvey, had violated CGS 53-82 Reckless Use of the Highway by Pedestrian, and that this was the contributing factor to this accident. Pedestrian was given a verbal warning for said violation. Nothing further. CaseOpen. Related Incident Number CTDOT- Case Status O - Open C - Closed O Officer Signature: Pamela Peters Officer First Name Pamela This report is a revision to a previously submitted report Officer Last Name Peters Supervisor:Mark Matthews Badge Number 63 Police Agency Code 23456 Date & Time : 2 0 4 0 6 2 0 0 2 Date & Time : 2 0 4 0 6 3 0 0 2
Page 3 of 7 Motor Vehicle ID: Number of occupants in Vehicle : (including the driver) VIN: Make: Model: Color: Year: Road on which vehicle was traveling: Congress Ave. For all numeric fields: = 'Unknown' SEQUENCE OF EVENTS (choose up to four, in chronological order) Non-Collision. Overturn/Rollover 02. Fire / Explosion. Immersion, Full or Partial 04. Jackknife 05. Cargo/Equipment Loss or Shift 06. Equipment Failure (blown tire, brake failure, etc) 07. Separation of Units 08. Ran Off Roadway Right 09. Ran Off Roadway Left 0. Cross Median. Cross Center Line 2. Downhill Runaway 3. Fell/Jumped From Motor Vehicle 4. Reentering Roadway 5. Thrown or Falling Object 6. Other Non-Collision Collision With Person, Motor Vehicle, or Non-Fixed Object 7. Pedestrian 8. Pedal Cycle/Pedal-cyclist 9. Other Non-motorist 20. Railway Vehicle (train, engine) 2. Animal (live) 22. Motor Vehicle In Motion 23. Parked Motor Vehicle 24. Struck By Falling, Shifting Cargo or Anything Set In Motion By Motor Vehicle 25. Work Zone/Maintenance Equipment 26. Other Non-Fixed Object Collision With Fixed Object 27. Impact Attenuator/Crash Cushion 28. Bridge Overhead Structure 29. Bridge Pier or Support 30. Bridge Rail 3. Cable Barrier 32. Culvert 33. Curb 34. Ditch 35. Embankment 36. Guardrail Face 37. Guardrail End 38. Concrete Traffic Barrier 39. Other Traffic Barrier 40. Tree (standing) 4. Utility Pole 42. Traffic Sign Support 43. Traffic Signal Support 44. Other Post, Pole, or Support 45. Fence 46. Mailbox st 2 nd 3 rd 4 th 7 Most Harmful Event 7 47. Other Fixed Object (wall, building, tunnel, etc.) 48. Light Support Form PR- REV July 24. MOTOR VEHICLE ACTION. Straight Ahead 02. Negotiating a Curve. Backing 04. Changing Lanes 05. Overtaking/Passing Motor Vehicle 06. Turning Right 07. Turning Left 08. Making U-Turn 09. Leaving Traffic Lane 0. Entering Traffic Lane. Slowing 2. Parked 3. Stopped in Traffic 4. Overtaking/Passing Cyclist 5. Wrong Way or Wrong Side 6. Traveling in Bike Lane CONTRIBUTING CIRCUMSTANCES MOTOR VEHICLE (choose up to 2). Brakes 02. Exhaust System. Body, Doors 04. Steering 05. Power Train 06. Suspension 07. Tires 08. Wheels 09. Lights (head, signal, tail) 0. Windows/Windshield. Mirrors 2. Wipers 3. Truck Coupling / Trailer Hitch / Safety Chains TOWED TO MOTOR VEHICLE INFORMATION POSTED/STATUTORY SPEED LIMIT (record the posted/statutory value as miles per hour). Not Posted 0, 5, 20, 25, 30, 35, 40, 45 50, 55, 60, 65, 70, 75, 80, 85 Motor Vehicle Information (Front) Complete One Sheet Per Motor Vehicle VIN missing or removed Driver Evaded Responsibility Direction of Travel N, S, E, W MOTOR VEHICLE CRASH INFORMATION TOWED. Towed Due to Disabling Damage 02. Towed, But Not Due to Disabling Damage. Not Towed Plate State: CT BODY TYPE. Passenger Car 02. (Sport) Utility Vehicle 02. Passenger Van 04. Cargo Van (<0,0 lbs GVWR) 05. Pickup 06. Motor Home 07. School Bus 08. Transit Bus 09. Motor Coach 0. Other Bus. Motorcycle 2. Moped 3. Low Speed Vehicle 4. Golf Cart 5. All Terrain Vehicle (ATV) 6. Snowmobile 7. Other Light Trucks (0,0 lbs GVWR or less) 8. Medium/Heavy Trucks (more than 0,0 lbs GVWR) INSURANCE INFORMATION 22-060536 Invalid Plate No Plate INSURANCE COMPANY INSURANCE POLICY NUMBER INSURANCE EXPIRATION DATE (yyyymmdd) E MOTOR VEHICLE DAMAGE EXTENT OF DAMAGE. No Visible Damage 02. Minor Damage. Functional Damage 04. Disabling Damage Plate #: Vehicle was not in roadway Unknown direction Use diagram above for values -2 See user guide for other vehicle diagrams. Initial Contact Point 3. Non-Collision 4. Top 5. Undercarriage 6. Cargo loss Damaged Areas (choose up to 3) 4. Top 5. Undercarriage 7. All Areas Total lanes in roadway: 2 Bike lanes/sharrows present MOTOR VEHICLE TYPE. Motor Vehicle in Operation 02. Parked Motor Vehicle. Working Vehicle/Equipment 04. Non-Collision Vehicle TRAFFICWAY DESCRIPTION. Two-Way, Not Divided 02. Two-Way, Not Divided w/ a Continuous Left Turn Lane. Two-Way, Divided, Unprotected (Painted >4 Feet) Median 04. Two-Way, Divided, Positive Median Barrier 05. One-Way Trafficway ROADWAY GRADE. Level 02. Uphill. Hill Crest 04. Downhill 05. Sag (bottom) ROADWAY ALIGNMENT. Straight 02. Curve Left. Curve Right TRAFFIC CONTROL DEVICE TYPE. No Control Device 02. Person (flagger, law enforcement, crossing guard, etc.). Traffic Control Signal 04. Flashing Traffic Control Signal 05. School Zone Sign/Device 06. Stop Sign 07. Yield Sign 08. Warning Sign 09. Railway Crossing Device 0. Marked Uncontrolled Crosswalk. Pedestrian Button 2. Bicycle Detection TRAFFIC CONTROL DEVICE FUNCTIONAL?. No. Missing
Page 4 of 7 Vehicle Owner Name (Last, First, Middle, Suffix) Form PR- REV July 24. Motor Vehicle Information (Back) Complete One Sheet Per Motor Vehicle MOTOR VEHICLE OWNERSHIP INFORMATION Information same as driver 22-060536 Street Address or Post Office Box City State/Prov Country Postal Code United States Email Address (optional) Phone (optional) For all numeric fields: = 'Unknown' SPECIAL VEHICLE FUNCTION. No Special Function 02. Taxi. Vehicle Used as School Bus 04. Vehicle Used as Other Bus 05. Military 06. Police 07. Ambulance 08. Fire Truck 09. Non-Transport Emergency 0. Incident Response Services Vehicle MOTOR VEHICLE INFORMATION SPECIAL VEHICLES EMERGENCY VEHICLE. Non-Emergency Situation, Not Transporting Patient 02. Non-Emergency Transport of Passenger. Emergency Operation, Emergency Warning Equipment Not in Use 04. Emergency Operation, Emergency Warning Equipment in Use BUS USE. Not a Bus 02. School. Transit/Commuter 04. Intercity 05. Charter/Tour 06. Shuttle Complete if public or private property other than vehicles were damaged in the crash NATURE AND EXTENT OF DAMAGE TO PROPERTY N/A PROPERTY DAMAGED NAME OF OWNER OF PROPERTY N/A NATURE AND EXTENT OF DAMAGE TO PROPERTY 2 NAME OF OWNER OF PROPERTY 2 NATURE AND EXTENT OF DAMAGE TO PROPERTY 3 NAME OF OWNER OF PROPERTY 3
Page 5 of 7 Name (Last, First, Middle, Suffix): unknown Street Address or PO Box: City: LICENSE INFO LICENSE NUMBER STATE CT ACTION BY OFFICER Taken. Verbal Warning 02. Written Warning. Infraction 04. Arrest/Summons Motor Vehicle ID: DRIVER LICENSE JURISDICTION. Not Licensed 02. State. Tribal Nation 04. U.S. Government 05. Canadian Province 06. Mexican State 07. International License (other than Mexico and Canada) 08. Valid License (other country) LICENSE CLASS. Class A 02. Class B. Class C 04. Class D 05. Class M COMMERCIAL LICENSE. No 02 ENDORSEMENTS A - Activity Vehicles F - Taxi, Livery, Motor Coach H - Hazardous Materials M - Motorcycles N - Tank Vehicles P - Passenger Q - Fire Fighting Vehicles S - School Bus T - Double/Triple Trailers V - Student Transportation X - Combination of Tank Vehicle and Hazardous Materials Person ID: For all numeric fields: = 'Unknown' EJECTION. Not Ejected 02. Ejected, Partially. Ejected, Totally AIRBAG. Not Deployed 02. Deployed-Front. Deployed-Side 04. Deployed-Curtain 05. Deployed-Other 06. Deployed-Combination SPEED RELATED. No 02. Racing. Exceeded Speed Limit 04. Too Fast for Conditions Form PR- REV July 24. State or Prov: RESTRAINT SYSTEM Used-Motor Vehicle Occupant. Shoulder and Lap Belt Used 02. Shoulder Belt Only Used. Lap Belt Only Used 04. Restraint Used Type Unknown Motor Vehicle Driver Information Complete One Sheet Per Driver 04 HELMET USE. No Helmet 02. DOT-Compliant Motorcycle Helmet. Helmet, Other Than DOT-Compliant Motorcycle Helmet 04. Helmet, Unknown If DOT-Compliant INJURY STATUS K. Fatal Injury A. Suspected Serious Injury B. Suspected Minor Injury C. Possible Injury O. No Apparent Injury O ENFORCEMENT ACTIONS TAKEN VIOLATION STATUTES Postal Code: GENDER. Male 02. Female. Unknown Phone/Email (optional): DRIVER INFORMATION SEATING POSITION FIRST DIGIT _. Front Row SECOND DIGIT _. Left Seat (usually the motor vehicle or motorcycle driver except for postal vehicles and some foreign vehicles) _2. Middle Seat _3. Right Seat _8. Other Seat 22-060536 INJURY AND EMS INFORMATION TRANSPORTED TO FIRST EMS COMPANY NAME MEDICAL FACILITY BY. Not Transported EMS RUN NUMBER 02. EMS Air. EMS Ground INTENDED RECEIVING FACILITY 04. Law Enforcement DATE OF BIRTH (YYYYMMDD) Date of Birth is unknown DRIVER ACTIONS (choose up to 4). No Contributing Action 02. Ran Off Roadway. Failed to Yield Right-of-Way 04. Ran Red Light 05. Ran Stop Sign 06. Disregarded Other Traffic Sign 07. Disregarded Other Road Markings 08. Improper Turn 09. Improper Backing 0. Improper Passing. Wrong Side or Wrong Way 2. Followed Too Closely 3. Failed to Keep in Proper Lane 4. Operated Vehicle in Reckless Aggressive Manner 5. Operated Motor Vehicle in Inattentive, Careless, Negligent, or Erratic Manner 6. Swerved or Avoided Due to Wind, Motor Vehicle, Object, Non-Motorist in Roadway, etc. 7. Over-Correcting/Over-Steering 8. Overtaking Cyclist Contributing Action DRIVER DISTRACTED BY. Not Distracted 02. Manually Operating an Electronic Communication Device (Texting, etc). Talking on Hands-Free Electronic Device 04. Talking on Hand-Held Electronic Device 05. Other Activity, Electronic Device 06. Passenger 07. Other Inside the Vehicle (eating, hygiene, etc.) 08. Outside the Vehicle CONDITION AT TIME OF CRASH (choose up to 2). Apparently Normal 02. Physically Impaired. Emotional (depressed, angry, etc.) 04. Ill (sick), Fainted 05. Asleep or Fatigued 06. Under the Influence (Medications/Drugs/Alcohol). Unknown DRUG/ALCOHOL INFORMATION ALCOHOL TEST STATUS TYPE OF ALCOHOL TEST. Test Not Given. Blood 02. Test Refused 02. Urine. Breath. Unknown if Tested TYPE OF DRUG TEST DRUG TEST STATUS. Test Not Given 02. Test Refused. Unknown if Tested. Blood 02. Urine
Page 6 of 7 Bicycle ID: Person ID: 2 Striking Motor Vehicle ID: Form PR- REV July 24. Non-Motorist Information Complete one sheet for each non-motorist involved in crash 22-060536 Road on which non-motorist was traveling/located: Congress Ave. For all numeric fields: = 'Unknown' Name (Last, First, Middle, Suffix): Street Address or P.O. Box: NON-MOTORIST PERSON TYPE. Pedestrian 04. Other Pedestrian (wheelchair, person in a building, skater, pedestrian conveyance) 05. Bicyclist 06. Other Cyclist 08. Occupant of a Non-Motor Vehicle Transportation Device INJURY STATUS K. Fatal Injury A. Suspected Serious Injury B. Suspected Minor Injury C. Possible Injury O. No Apparent Injury C ACTION BY OFFICER Taken. Verbal Warning 02. Written Warning. Infraction 04. Arrest/Summons Happy Place City: Newington IDENTIFICATION INFO IDENTIFICATION NUMBER ISSUED BY Harvey, Paula, D DRIVER LICENSE JURISDICTION. Not Licensed 02. State. Tribal Nation 04. U.S. Government 05. Canadian Province 06. Mexican State 07. International License (other than Mexico and Canada) 08. Valid License (Other Country). Unknown State or Prov: CT NON-MOTORIST ACTION/ CIRCUMSTANCE PRIOR TO CRASH. Crossing Roadway 02. Waiting to Cross Roadway. Walking/Cycling Along Roadway With Traffic (In or Adjacent to Travel Lane) 04. Walking/Cycling Along Roadway Against Traffic (In or Adjacent to Travel Lane) 05. Walking/Cycling on Sidewalk 06. In Roadway - Other (Working, Playing, etc.) 07. Adjacent to Roadway (e.g., Shoulder, Median) 08. Working in Trafficway for Incident Response NON-MOTORIST ACTION/ CIRCUMSTANCES AT TIME OF CRASH (choose up to 2). No Improper Action 02. Dart/Dash. Failure to Yield Right-Of-Way 04. Failure to Obey Traffic Signs, Signals, or Officer 05. In Roadway Improperly (Standing, Lying, Working,Playing) 06. Disabled Vehicle Related (Working on, Pushing, Leaving/Approaching) 07. Entering/Exiting Parked/Standing Vehicle 08. Inattentive (talking, eating, etc.) 09. Not Visible (Dark Clothing, No Lighting, etc.) 0. Improper Turn/Merge. Improper Passing 2. Wrong-Way Riding or Walking 2 3. Use of Electronic Device TRANSPORTED TO FIRST MEDICAL FACILITY BY. Not Transported 02. EMS Air. EMS Ground 04. Law Enforcement ENFORCEMENT ACTIONS TAKEN VIOLATION STATUTES CGS 53-82 NON-MOTORIST INFORMATION Postal Code: 06 Non-motorist was not in roadway Unknown direction GENDER. Male 02. Female. Unknown Phone/Email (optional): NON-MOTORIST LOCATION AT TIME OF CRASH. Intersection - Marked Crosswalk 02. Intersection - Unmarked Crosswalk. Intersection - Other 04. Mid Block - Marked Crosswalk 05. Travel Lane - Other Location 06. Bicycle Lane 07. Shoulder/Roadside 08. Sidewalk 09. Median/Crossing Island 0. Driveway Access. Shared-Use Path or Trail 2. Non-Trafficway Area 3. Sharrow/Shared Lane Marking 05 NON-MOTORIST SAFETY EQUIPMENT (choose up to 2). Helmet 02. Protective Pads Used. Reflective Clothing 04. Lighting 05. ANSI Approved Bicycle Helmet INJURY AND EMS INFORMATION EMS COMPANY NAME EMS RUN NUMBER AMR none INTENDED RECEIVING FACILITY none 02 DRUG TEST STATUS. Test Not Given 02. Test Refused. Unknown if Tested Direction of travel (N, S, E, W): Only required if the crash involves a non-motorist DATE OF BIRTH (YYYYMMDD) NON-MOTORIST DISTRACTED BY. Not Distracted 02. Manually Operating an Electronic Communication Device (Texting, etc). Talking on Hands-Free Electronic Device 04. Talking on Hand-Held Electronic Device 05. Other Activity, Electronic Device 06. Other Activity, Inside the Vehicle (eating, hygiene, etc.) 07. Other, Outside the Vehicle GOING TO / FROM SCHOOL. No E NON-MOTORIST CONDITION AT TIME OF CRASH (choose up to 2). Apparently Normal 02. Physically Impaired. Emotional (depressed, angry, etc.) 04. Ill (sick), Fainted 05. Asleep or Fatigued 06. Under the Influence (Meds/Drugs/Alcohol) 9 9 2 0 8 2 Date of Birth is unknown DRUG/ALCOHOL INFORMATION ALCOHOL TEST STATUS TYPE OF ALCOHOL TEST. Test Not Given. Blood 02. Test Refused 02. Urine. Breath. Unknown if Tested TYPE OF DRUG TEST. Blood 02. Urine
Page 7 of 7 Form PR- REV July 24. Appendix A: Narrative Continued Complete this sheet if more space is needed for the narrative NARRATIVE CONTINUED (i) 22-060536