INCIDENT REPORT

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 06838464
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 6
• Document Creation Date: March 9, 2023
• Document Release Date: January 31, 2020
• Case Number: F-2019-01647
• Publication Date: October 30, 2018

Approved for Release: 2020/01/28 C06838464
TOTAL NUMBER OF
VEHICLES INVOLVED
Central Intelligence Agency
DATE OF CRASH TIME (0000) DISTRICT/DONE TROOP
1_10 .3_10 )2 0 '1 .8 '0 7 1 5 GBCI
PARISH PARISH CODE
CITY OR TOWN.
CRASH
OCCURRED ON
A. inTEITSTAIE
BUS. IhvY
C. STATE !MY
D.PARISH ROAD
E ctlY STREET
r. OFF noAo.,
PRIVATE PROPERTY
G TOLL ROAD
HIGHWAY I, MILEPOST
_
DISTANCE
DISTANCE
MILES 0
FEET 0
MILES 0
FEET 0
NE
S W , . 1
STREET/HIGHWAY AT INTERSECTION NOT AT INTERSECTION
NE
S W _
I
,LAT. �
NLJ E
sLI w n
O.
LONG.
Quadrant Sarvico Road
CITY CODE
NW J SW
NE [7 SE _
ROADWAY NAME
[0.0 '9 �3 ,0 Df0 ,L ,E Y, �MA DJ SO
STREET/HIGHWAY ; I AT INTERSECTION C NOT AT INTERSECTION.
-
1800034207
TIORK
zoNE
PUBLIC
PROPERTY
DAMAGE
PAGE a
01
KR 6
RuN
PHOTOS
MADE
RR ITIA/N FATALITY
i/NOLVED
PAD
INJUITy
WRITE APPROPRIATE LETTER IN BLOCK CONTRIBUTING FACTORS AND CONDITIONS
ROAD SURFACE
ROADWAY --
I
TYPE OF ROADWAY
ALIGNMENT
PRIMARY FACTOR
(ONE PER COLUMN)
CONDITIONS
�
B
A 1 1 1
IA i
IC.
A. NO ABNORMALITIES
B. SHOULDER ABNORMALITY
HOLES
A. ONE-WAY ROAD
B. TWO-WAY ROAD WITH
NO PHYSICAL SEPARATION
A. ST RAiGNT�LEVEL
B. STRAIGHT-LEvEL ELEVATED
C. CURVE-LEVEL
SECONDARY FACTOR
A. DRY
A. CONCRETE
D. DEEP RUTS
C. TWO-WAY ROAD WITH A
D. CURVE-LEVEL ELEVATED
E. GRA0E-STRAIGHT
A. WOLATTONS
B. WET
B. BLACK TOP
E. DUMPS
PHYSICAL SEPARATION
ON
0. MOVEMENT PRIOR TO CRASH
C. SNOW/SLUSH
C. BRICK
F. LOOSE SURFACE MATERIAL
D. TWO-WAY ROAD WITH A
F. ON GRADE-CURVE
C. VISIon oBSCUSEMENTS
D. ICE
D. GRAVEL
G. CONSTRUCTION. REPAIR
PHYSICAL BARRIER
G. HitICREST-STRAiGHT
D. CONDITION OP DRIVER
E CONTAMINANT
B. DIRT
H. OVERHEAD CLEARANCE LIMITED
Y. UNKNOWN
H. HILLCREST-CURVE
E. VEHICLE CONDITIONS
(SAND. MUD.
v, UNKNOWN
I. CONSTRUCTION. NO WARNING
Z. OTHER
T. DIP. HUMP-STRAIGHT
F. ROAD SURFACE
DIRT. OIL. ETC.)
2. OTHER
J. PREVIOUS CRASH
J. DIP. HUmP.CURVE
G. ROADWAY CO/0110N
P. UNKNOWN
K. WATER ON ROADWAY
Y. UNKNOWN
H. uonnuo
2. OTHER
L ANIMAL IN ROADWAY
Z. OTHER ....... ........ ... .........
I. WEATHER
M. OBJECT IN ROADWAY
J. TRAFFIC CONTROL
Z. OTHER
RELATION TO
ACCESS CONTROL
K. KIND OF LOCATION
WEATHER
ROADWAY
L CONDITION OF PEDESTRIAN
KIND OF LOCATION
�
M. PEDESTRIAN ACTIONS
A. CLEAR A I
LIGHTING
B.CLOUDY -.
A. ON ROADWAY
A. NO CONTROL
C. RAIN
_.;
B. SHOULDER
rurtumTTED ACCESS TO
A. DAYLIGHT A
D. FOG/SMOKE
C. MEDIAN
ROADWAY)
B. DARK � NO STREET
E. SLEET/HAIL
F. SNOW
G.SEVERE CROSSWIND
A. MANUFACTURING OR INDUSTRIAL
B. BUSINESS CONTINUOUS
C. BUSINESS. MIXED RESIDENTIAL
D. RESIDENTIAL DISTRICT
O. BEYOND SHOULDER � LEFT
E. BEYOND SHOULDER- RIGHT
F. BEYOND RIGHT OF WAY
0. GORE
B. PARTIAL CONTROL
LIMITED ACCESS TO ROADWAY
C. FUU. CONTROL
(ONLY RAMP ENTRANCE & EXIT)
LIGHTS
C. DARK � CONTINUOUS STREET
LIGHT
D. DARK -- STREET UGHT AT
H. BLOWING SAND, SOIL
DIRT, SNOW
E. RESIDENTIAL SCATTERED
F. SCHOOL OR PLAYGROUND
Y. UNKNOWN
Z. OTHER
Y. UNKNOWN
2. OTHER
INTERSECTION ONLY
E. DUSK
Y. UNKNOWN
G. OPEN COUTMIY
F. DAWN
Z. OTHER
Z. OTHER .,
V. UNKNOWN
Z. OTHER ...
A dsala
PASSENGER
CAR
D oar-se
A. B. C. OR S
WITH TRAILER
VEMCLE
-
G eis
OFF-ROAD
VEHICLE
COIVKIUNATION
J ifKiJ
BUS W/SEATS
FOR 9 -15
OCCUPANTS
M Mg
SINGLE UNIT
TRUCK W/ 3
AXLES OR MORE
Q OPIP
TRACTOR
SEMI-TRAILER
T
FARM
EQUIPMENT
BeiliwoE
LT. TRUCK
(P.U.. ETC.)
�610HalliKNIORIPI
MOTORCYCLE
EMERGENCY
VEHICLE IN
USE
TRUCK/
TRAILER
RMINVOIN
TRUCK
DOUBLE
MOTOR
HOME
BUS W/SEATS
FOR 113 on
MORE OCC.
C eggin
VAN
F eiVii
PEDALCYCLE
L ON
SINGLE UNIT
TRUCK W/ 2
AXLES
P NIL,
TRUCK!
TRACTOR
S OM
SLTV
z
OTHER
I
SCHOOL BUS
CARGO BODY
TYPE
Gerax.
AUTO
TRANSPORTER
J gm
HOPPER
Ail
BUS
DI�Tr
FLATBED
BRIIIFIE1162111%,K.1_44.
VAN/ENCLOSED
BOX
LOG TRUCK/
TRAILER
DUMP TRUCK/
TRAILER
POLE TRAILER
C WRY
CARGO TANK
Fogg
CONCRETE
MIXER
IONS
GARBAGE/
REFUSE
X
no
CARGO
Door
Z
OTHER
TIME CALLED
EMERGENCY 7
SERVICES mauLANcE FT I 1-1
1
AMBULANCE
SERVICE
ARRIVED SCENE DEPARTED SCENE ARRIVED HOSPITAL
FIRE
DEPARTMENT
TIME CALLED
RESCUE
UNIT I ,
ARRIVED SCENE
7 ET
INVESTIGATING
AGENCY _CIA
INVESTIGATION
COMPLETE
NAME OF AGENCY
TIME OF NOTIFICATION
0 17 3
[INVESTIGATING -
POLICE A STATE C. PARJ
AGENCY 0 are z. oThol I
TIME OF ARRIVAL
0 7 !2 )0
DATE REPORT COMPLETED
TIME ALL LANES OPENED
110 Y 2 10
INVESTIGATING OFFICERS NAUE (PRINT) SIGNATURE BADGE. SUPERVISOR'S
INMALS OR BADGE.
DPSSP 3105 (REV. JAN. 2005)
Approved for Release: 2020/01/28 C06838464
Approved for Release: 2020/01/28 C06838464
the road. The first vehicle, a blue Volkswa on Passat with the ta
waiting. I walked up to the driver, Mr. and asked what happened. Mr.
that while waiting at the stop sign by , e was trying to make a left hand turn to
vehicle a Hyundai Accent tag
t. He said he thought the roa was safe to take a left turn. When he out he hit Ms
I then approached Ms. vehicle and asked her
what happened. She stated she was driving from the George Washington Parkway entrance and was
ratien ting to make a left towards green lot. When Ms tarted to make the left hand turn Mr.
pulled out and struck the driver side of her vehicle. There was a dent in Ms
scratches on the driver side front bumper of his vehicleorrned both drivers there would be a
vehicle just before the driver side rear wheel well. Mr. had minor paint transfer and some
police report, and had them exchange insurance forms. Neither driver had any visible injuries and the
scene was cleared at approximately 0735 hours.
OFFICER'S NARRATIVE: DESCRIBE ANY UNUSUAL CIRCUMSTANCES ASSOCIATED WITH CRASH, INCLUDING OFFICERS OBSERVATIONS AND OPINIONS.
(b)(3) INCLUDE WITNESS NAMES, ADDRESSES. PHONE NUMBERS, ETC.
IF NECESSARY. INDICATE DAMAEID_EUBUG yATE_FROFFECTaMmi otroNEFrs NA_ME_6__A_OORESSAAT THE_END OF_IFIEBABI3A,MvE,
REFER TO EACH BY VEHICLE NUMBER
(b)(6)
On 10/30/2018 at 0715 I Office while working was dispatched to a traffic collision with no (b)(6)
injuries. I arrived at approximately 0720 hours. I observed two vehicles pulled off to the side of
was sitting there
informed me
nve towards
(b)(3)
(b)(6) (b)(3)
(b)(6)
(b)(3) (b)(6)
(b)(3)
(b)(6)
(b)(3)
(b)(6)
PAGE 4
2 !
0
(b)(3)
(b)(6)
(b)(3)
(b)(6)
(b)(3)
(b)(6)
(b)(3)
(b)(6)
NONCOLLISION
%MP MOTOR
Wier-LE
A
REAR ENID HEAD-ON
.411.�40.. .0-
E1
HIGHT ANGLE
LEFT TURN
E
LEFT TURN LEFT TURN latwr TURN mew TWIN =MILK VOESWIPE
SAME OPPOSITE
.411�
F I G HflFI J K
OTHER MANNER OF
COLLISION _
0
NORD.'
Approved for Release: 2020/01/28 C06838464
Approved for Release: 2020/01/28 C06838464
PAGE P
1 VEH
OR
CONE CARGO BODY TYPE
see page 1 for
A X selections
Central Intelligence Agencyi 5 9 1
PEDESTRIAN
YEAR MAKE
2009 HY UN
"." 0000000000000
LICENSE
PLATE
YEAR
2019
YEAR
TRAILER
DESCRIPTION
STATE NUMBER
MAKE
MODEL
ACCENT
VEHICLE
TOWED N
AYES REMOVED
B NO BY
C. LEFT AT SCENE
-03
DOORS 11 AXLES
2
TIRES
TYPE
GVWFVGCWR
REASON TOWED
A VEKCII E DAMAGE
DR.VER ARRESTED
C :NSURANCE VIOLATION
Z OTHER
TYPE
YEAR
STATE
NUMBER
LICENSE
PLATE
VEHICLE
CLASSIFICATION
COMMERCIAL/
BUSINESS VEHICLE
GOVERNMENT VEHICLE PERSONAL VEHICLE X
CARRiER NAME
STREET ADDRESS:
INTERSTATE CAHRER YiN
TRANSPORTING HAZARDOUS MATERIAL
CITY _
CLASS :41 IDII
US DOT
MC/MX rICC")
STATE_ _ ZIP
PLACARDS D:SPLAYED
(-(AZ MAT ,
REL EASED YiN
NAME (LAST. FIRST, MI) OF X DRIVER PEDESTRIAN
STREET AFITIRFCR
CITY
STATE CLASS EIATJFISEI:i_NTS DRIVER:5 LICENSE NUMBER
PEDESTRIAN ONLY
UPPER BODY
CLOTHING LIGHT DARK
TELEPHONE I,
STATE
LOWER BODY
CLOTHING LIGHT DARK
YIN y
NAME CI
TATtLI TX
SEX
DATE OF
DIRT
ea,
A AB F
TRANSPORTED TO MEDICAL FACILITY
A YES O. REFUSED AD
B. NO Y. UNKNOWN N
RACE AGE
INJURY CODE
OWNER'S NAME (LAST. FIRST. MI OR COMPANY NAME)
Same as
X Driver
STREET ADDRESS
CITY
STATE
TELEPHONE
ZIP
INSURANCE CO. NAME GE/CO
AGENTS NAME/ADDRESS
iNnT AGENCY NAME1
POUCY NUMBER
EXPIRATION DAM
PHONE p 0-
OCCUPANT'S NAME (LAST. FIRST, MI)
STREET ADDRESS
CITY
STATE
ZIP
TRANSPORTED TO MEDICAL FACILITY
A. YES C. REFUSED AID
B. NO V UNKNOWN
PC'
"
NAME Of
TACO TY
OCCUPANT'S NAME (LAST. FIRST, MI)
STREET ADDRESS
CITY
STATE
ZIP
TRANSPORTED TO MEDICAL FACILITY
A. YES C. REFUSED AID
0. No Y. UNKNOVJN
NAME
FACILITY
SEATING POSITION
A. FRONT SEAT-LEFT SIDE
(MOTORCYCLE DRIVER)
B - FRONT SEAT-MIDDLE
C � FRONT SEAT-RIGHT SIDE
D � SECOND SEAT-LEFT 5105
(MOTORCYCLE PASSENGER)
E SECOND SEAT-MIDDLE
F � SECOND SEAT-RIGHT SIDE
G THIRD ROW-LEFT SIDE
(MOTORCYCLE PASSENGER)
H - THIRD ROW-MIDDLE
I � THIRD ROW-RIGHT SIDE
EJECTION
J � SLEEPER SECTION OF CAB (TRUCK) A- NOT EJECTED
K � PASSENGER IN OTHER ENCLOSED B- TOTALLY EJECTED
PASSENGER OR CARGO AREA C- PARTIALLY
(NON-TRAILING UNIT)
EJECTED
� PASSENGER IN OTHER UNENCLOSED
PASSENGER OR CARGO AREA (NON- Y- UNKNOWN
TRAILING UNIT)
m- PASSENGER ON TRAIN OR STREETCAR
N. TRAILING UNIT
0. RIDING on VEHICLE EXTERIOR (NON.
TRAILING UNIT'
Y� UNKNOWN
TRAPPED OR
EXTRICATED
A- NOT TRAPPED
B�TRAPPED/EXTRI-
CATE0
C-TRAPPED/NOT
EXTRICATED
Y- UNKNOWN
AIRBAG
A- DEPLOYED
B- NON
DEPLOYED
C�NON-DEPLOY-
ED/SWITCH
OFF
0-NOT
APPLICABLE
Y. UNKNOWN
OCCUPANT PROTECTION
SYSTEM USED
A� NONE USED-VEHICLE
OCCUPANT
B�SHOULDER BELT ONLY USED
C- LAP BELT ONLY USED
0-SHOULDER AND LAP BELT
USED
E- CHILD SAFETY SEAT
IMPROPERLY USED
F- CHILD SAFETY SEAT USED
0-HELMET USED
Y- RESTRAINT USE UNKNOWN
INJURY
A� FATAL
8-INCAPACITA-
TING/SEVERE
C�NON-INCAPA-
CrTATING/
MODERATE
ID� POSSIBLE/
COMPLAINT
E- NO INJURY
DPSSP 3106 (REV JAN 2055)
Approved for Release: 2020/01/28 C06838464
Approved for Release: 2020/01/28 C06838464
PAGE #
0 4
WRITE APPROPRIATE LETTER IN BLOCK CONTRIBUTING FACTORS AND CONDITIONS
CONDITION
SEQUENCE OF EVENTS/HARMFUL EVENTS
NON COLLISION S. MOTOR VEHICLE IN TRANSPORT
A. OVERTuRNMOLLOYER T. PARKED MOTOR VEHICLE
LL TRAFFIC SIGN SUPPORT
MM. TRAFFIC SIGNAL SUPPORT
VISION
OBSCUREMENTS Lts1 I
OF DRIVER/PED
A. NORMAL
B. FIRE/EXPLOSION
U. STRUCK BY FALLING, SHIFTING
NH. OTHER POST, POLE. OTT
A. RAIN. SNOW, ETC. ON WINDSHIELD
B. INATTENTIVE
C. IMMERSION
CARGO OR ANYTHING SET IN monoN
SUPPORT
B. WINDSHIELD OTHERWISE OBSCURED
C. DISTRACTED
D. JACKKNIFE
BY MOTOR VEHICLE
00, FENCE
C. VISION OBSCURED BY LOAD
D. ILLNESS
E. cAncomoutpmerr LOSS OR shrr
V. WORK ZONE/MAINTENANCE
PP. MAILBOX
D. TREES, BUSHES. ETC.
E. FATIGUED
F. FELL/JUMPED FROM LTOTOF/ VEHICLE
EOUIPmENT
00. OTHER FIXED OBJECT (WALL
E. BUILDING
F. EMBANKMENT
F. APPARENTLY ASLEEPIBLACKOUT
0. DRINKING ALCOHOL � IMPAIRED
G. THROWN OR FALLING OBJECT
H, EOUIPMENT FAILURE (BLOWN
W. OTHER NON-FIXED OBJECT
BUILDING, TUNNEL. ETC.)
YY. UNKNOWN
G. SIGN BOARDS
H. HILLCREST
H. DRINKING ALCOHOL. NOT IMPAIRED
I. DRUG USE � IMPAIRED
TIRE, BRAKE FAILURE, ETC.)
I. SEPARATION OF UNITS
COLLISION_WITH FIXED_OBJECL
X. IMPACT ATTENUATOR�CRASH CUSHION
I. PARKED VEHICLES
J. DRUG USE � NOT IMPAIRED
IN TRANSPORT
Y. BRIDGE OVERHEAD STRUCTURE
J. MOVING VEHICLES
K. PHYSICAL IMPAIRMENT
J. RAN OFF ROAD RIGHT
Z BRIDGE PIER OR SUPPORT
101
K. BLINDED BY HEADUGHTS
(EYES. EAR. UM13)
K..FIAN OFF ROAD LEFT
V.A. BRIDGE RAIL
L BLINDED BY SUNGLARE
Y. UNKNOWN
L CROSSED MEDIAN/CENTERLINE
DEL CULVERT
M. DISTRACTED BY NEON LIGHTS IN
Z. OTHER
M. DOWNHILL RUNAWAY
CC. CURB
2nd Y
Y
FIELD OF VIEW
N. OTHER NON.COLUSION
Da DITCH
DRIVER
DISTRACTION IE_ I
N. NO OBSCUREMENTS
T. UNKNOWN
Z. OTHER
coLusign, WITH PERSQN,A9198
EE. EMBANKMENT
FF. GUARDRAIL FACE
CIG. GUARDRAIL END
3rd Y
,Y
VEHLOI.E-9.110_0121:11XEOS/B.JECI
A CELL PHONE
0. PEDESTRIAN
NH. CONCRETE TRAFFIC BARRIER
B. OTHER ELECTRONIC DEVICE
(PAGER. PALM PILOT, NAVIGATION
DEVICE. ETC.)
P. PEDALCYCLE
0. RAILWAY VEHICLE (TRAIN, ENGINE)
P. ANIMAL
OTHER TRAFFIC BARRIER
JJ. TREE (STANDING)
RN. TJTIUTY POLE/LIGHT SUPPORT
4th Y
MOST HARMFUL
Yi
EVENT
VIOLATION
Li
A. EXCEEDING STATED SPEED UMIT
B. EXCEEDING SAFE SPEED Limn-
C. FAILURE TO YIELD
D. FOLLOWING TOO CLOSELY
C. OTHER INSIDE THE VEHICLE
D. OTHER OUTSIDE THE VEHICLE
E. NOT DISTRACTED
Y. UNKNOWN
MOVEMENT PRIOR TO CRASH I ,
I/
is ;
ENTERING TRAFFIC FROM
SHOULDER
E. DRIVING LEFT OF CENTER
F. CUTTING IN. IMPROPER PASSING
A. STOPPED
B. PROCEEDING STRAIGHT AHEAD
K. STOPPED PREPARING TO,
OR MAKING u-TuRN
T.
REASON FOR
G. FAILURE TO SIGNAL
MOVEMENT
C. TRAVELING WRONG WAY
L MAKING TURN. DIRECTION
U. ENTERING TRAFFIC FROM
H. MADE WIDE RIGHT TURN
D. BACKING
UNKNOWN
MEDIAN
I. CUT CORNER ON LEFT TURN
J. TURNED FROM WRONG LANE
K. OTHER IMPROPER TURNING
L DISREGARDED TRAFFIC CONTROL
A. TO AVOID OTHER VEHICLE
B. TO AVOID PEDESTRIAN
C. TO AVOID ANIMAL
D. TO AVOID OTHER OBJECT
E. CROSSED MEDIAN INTO
OPPOSING LANE
F. CROSSED CENTER LINE INTO
M. STOPPED. PREPARING TO
TURN LEFT
N. STOPPED, PREPARING TO
V ENTERING TRAFFIC FROM
PARKING LANE
W. ENTERING TRAFFIC FROM
M. IMPROPER STAFMNG
E. PASSING
OPPOSING LANE
TURN RIGHT
PRIVATE LANE OR DRIVEWAY
N IMPROPER PARKING
0. FARED TO SET OUT FLAGS, FLARES
F. VEHICLE OUT OF CONTROL,
NOT PASSING
G. RAN OFF ROAD (NOT WHILE
MAKING 11JRN AT INTERSECTION)
0. SLOWING TO MAKE LEFT TURN
P. SLOWING 10 MAKE RIGHT
X. ENTERING FREEWAY FROM
ON RAMP
P. FAILED TO DIM HEADLIGHTS
G. VEHICLE OUT OF CONTROL PASSING
H. CHANGING LANES ON
TURN
T. LEAVING FREEWAY VIA
0. VEHICLE CONDITION
H. FOR TRAFFIC CONTROL
MUUI-LANE ROAD
0. SLOWING TO STOP
OFF RAMP
R. DRIVER CONDITION
I. DUE TO CONGESTION
I. MAKING LEFT TURN
R. PROPERLY PARKED
Z. OTHER OR UNKNOWN
S. CARELESS OPERATION
J. DUE TO PRIOR CRASH (COLUstON)
J MAKING RIGHT TURN
S. PARKING MANEUVER
T. IMPROPER BACKING
K. DUE TO DRIVER CONDITION
VEHICLE
U. NO VIOLATIONS
Y. UNKNOWN
L DUE TO DRIVER VIOLATION
M. DUE TO VEHICLE CONDITION
Z. OTHER
(FAILURE)
CONDITION K
ALCOHOL/DRUG
N. DUE 10 PAVEMENT CONDITION
0. HIGH WIND
A. DEFECTIVE BRAKES
INVOLVEMENT
TRAFFIC
P. NORMAL MOVEMENT
Y. UNKNOWN
B. DEFECTIVE HEADLIGHTS
C. DEFECTIVE REAR UGHTS
ALCOHOL/DRUBS SUSPECTED A:
CONTROL _A ;
Z. OTHER
D. DEFECTIVE SIGNAL LIGHTS
E. ALL LIGHTS our
A. NEITHER ALCOHOL NOR DRUGS
B. YES�ALCOHOL
PEDESTRIAN
ACTIONS
A. STOP SIGN
B. YIELD SIGN
C. RED SIGNAL ON
I, DEFECTIVE STEERING
G. TIRE FAILURE
H. WORN OR SMOOTH TIRES
L ENGINE FAILURE
C. YES�DRUGS
D. YES�ALCOHOL AND DRUGS
Y. UNKNOWN
D. YELLOW SIGNAL ON
A. CROSSING. ENTERING ROAD
J. DEFECTIVE SUSPENSION
E. GREEN SIGNAL ON
AT INTERSECTION
K. NO DEFECTS OBSERVED
F. GREEN TURN ARROW ON
B. CROSSING, ENTERING
Y. UNKNOWN
ALCOHOL
G. RIGHT TURN ON RED
ROAD NOT AT INTERSECTION
Z. OTHER
A. TEST REFUSED
H. UGHT PHASE UNKNOWN
I. FLASHING YELLOW
J. FLASHING RED
K. OFFICER. FLAGMAN
C. WALKING IN ROAD - WITH
TRAFFIC
D. WALKING IN ROAD - AGAINST
VEHICLE
LIGHTING
B. NO TEST GIVEN
C. TEST GIVEN. RESULTS PENDING
� D. TEST GIVEN, BAC I . a%
L RR CROSSING. SIGN
M. RR CROSSING,SIGNAL
N. RR CROSSING, NO CONTROL
0. WARNING SIGN (SCHOOL ETC.)
TRAFFIC
E. SLEEPING IN ROADWAY
F. STANDING IN ROADWAY
G. GETTING ON OR OFF OTHER
A. HEADLIGHTS ON
B. HEADLIGHTS OFF
C. DAYTILIE RUNNING UGHTS
Y UNKNOWN
DRUGS
A. TEST NOT GIVEN
P. SCHOOL FLASHING SPEED SIGN
VEHICLE
TRAFFIC
0. TEST GIVEN. RESULTS PENDING
0. YELLOW NO PASSING LINE
R. WHITE DASHED LINE
H. PUSHING. WORKING ON
VEHICLE IN ROAD
CONTROL
C. TEST REFUSED
D. DRUGS REPORTED (SPECIFY IN NARRATIVE)
S. YELLOW DASHED LINE
I. OTHER WORKING IN
CONDITIONS
T. DIKE LANE
ROADWAY
A. CONTROLS FUNCTIONING
U. CROSSWALK
J. PLAYING IN ROADWAY
B. CONTROLS NOT FUNCTIONING
AFFIX aLoort ALCOHOL KIT LABEL HERE
V. NO CONTROL
K. NOT IN ROADWAY
C. CONTROLS OBSCURED
Y. UNKNOWN
Z. OTHER
Y. UNKNOWN
Z. OTHER
D. LANE LLARKiNG UNCLEAR
OR DEFECTIVE
E. NO CONTROLS
(OR ENTER BLOOD ALCOHOL KIT NUMBER)
T. UNKNOWN
DIRECTION BEFORE CRASH
HEADED
N E
I SW
ON HIGHWAY. STREET OR DRIVE
FINAL LOCATION
OF VEHICLES
DISTANCE TRAVELED
AFTER IMPACT
EST.
DAMAGE TO VEHICLE
AREA DAMAGED
C 0 E
I I ,F ISTIt
A _ -
1..**/ I
CARRIAGE 2ND
1.1/IDER.
0. TOTAL -
P. OTHER
0. NONE 3R0 [
Y. UNKNOWN
EXTENT OF DEFORMITY
A. NONE
ID1ST VME, NR YO MINOR
C.0- :1TE
F MINOR/MODERATE
L___,2ND E. MODERATE
MODERATE/SEVERE
[
0- SEVERE
3RD H'VERY SEVERE
'KUNKNOWN
CITATION NO
SPEE
POSTED
VEH. PED.
FR
$,KIDMARK(GATA (FEkT)
FL RR
RL
ELS-OB GPO. NO
0
C:1
Do
Do
00
NOTICE OF INSURANCE VIOLATION
DPSSP 3106 REV. JAN. 2005)
Approved for Release: 2020/01/28 C06838464
INVESTIGATING OFFICER'S INITIALS
Approved for Release: 2020/01/28 C06838464
X
PAGE #
OR
0 2 MEN N 0 PEDESTRIAN
CONF CARGO BODY TYPE
See page 1 for
A X selections
Central Intelligence Agency 1 5 9 1
YEAR MAKE
2013 VOL K
"." 000000000 oo oo oo
LICENSE
PLATE
YEAR
2 0 1
YEAR
TRAILER
DESCRIPTION
VEHICLE
TOWED
MODEL
PAS SAT
A YES
B NO
C. LEFT AT SCENE
REMOVED
BY
- 05
if Dioons if AXLES
4
if TIRES
STATE
NUMBER
TYPE
GVWR/GCWR
REASON TOWED
A ASH CIE DAMAGE
B DRYER ARRESTED
9
C INSURANCE ViOLACON
L OTHER
MAKE
TYPE
YEAR
STATE
NUMBER
VEHICLE
CLASSIFICATION
CO(.1MERCIALJ
BUSINESS VEHICLE
GOVERNMENT VEHICLE
LICENSE
PLATE
PERSONAL VEHICLE X 1
CARRIER NAME
STREET ADDRESS: _
INTERSTATE CARRIER YIN
TRANSPORTING HAZARDOUS MATERIAL \IN
crry
CLASS (DO
NAME (LAST. FIRST, MI) OF X DRIVER PEDESTRIAN
STREET ADDRESS
CITY
STATE
CLASS ENDCRSEmENTS oRivER'S LICENSE NUMBER
PEDESTRIAN ONLY
UPPER BODY
CLOTHING LIGHT DARK
STAT
(b)(3)
(b)(6)
TELEPHONE h
US DOT
MC/MX MCC") A
STATE ZIP
PLACARDS DISPLAYED IN
HAZ MAT
RELEASED 'IN
TO
ECHT
LOWER BODY
CLOTHING LIGHT DARK
y/N y .11. AA
SEX
DATE OF
DIRT
c.ett
AAB
TRANSPORTED TO MEDICAL FACILITY
A. YES C. REFUSED AID
B. NO Y. UNKNOWN N
(b)(6)
RACE AGE
M,14#
INJURY CODE
OWNER'S NAME ILAST, FIRST, MI OR COMPANY NAME)
Same as
Driver
STREET ADDRESS
CITY
STATE
TELEPHONE r(
ZIP
INSURANCE CO. NAME PROGRESSIVE
INCT ALENCY NAME)
AGENT'S NAME ADDRESS
POLICY NUMBER
EXPIRATION DATE #
PHONE a 0-
OCCUPANTS NAME (LAST, Tins'''. MI)
STREET ADDRESS
CITY
STATE
ZIP
TRANSPORTED TO MEDICAL FACILITY
A. YES C REFUSED AID
B. NO Y UNKNOWN
CC .
NAME Cr
FACIU IV
OCCUPANTS NAME (LAST. FIRST. MI)
STREET ADDRESS
CITY
STATE
ZIP
TRANSPORTED TO MEDICAL FACILITY
A. YES C. REFUSED AID
D. NO Y. UNKNOWN
t:Ar.�.E.
Di-
rACLIrY
SEATING POSITION
A - FRONT SEAT-LEFT SIDE
(MOTORCYCLE DRIVER)
B - FRONT SEAT�MIDDLE
C - FRONT SEAT�RiGHT SIDE
� SECOND SEAT-LEFT SIDE
(MOTORCYCLE PASSENGER)
E � SECOND SEAT-MIDDLE
F � SECOND SEAT-RIGHT SIDE
G - THIRD ROW-LEFT SIDE
(MOTORCYCLE PASSENGER)
H - THIRD ROW-MIDDLE
I � THIRD ROW-RIGHT ODE
J � SLEEPER SECTION OF CAB (TRUCK)
K - PASSENGER IN OTHER ENCLOSED
PASSENGER OR CARGO AREA
(NON-TRAILING UNIT)
L - PASSENGER IN OTHER UNENCLOSED
PASSENGER OR CARGO AFIEA (NON-
TRAiUNG UNIT)
FL-PASSENGER ON TRAIN OR STREETCAR
N� TRAILING UNIT
0- RIDING ON VEHICLE EXTERIOR (NON-
TRAILING UN(1)
Y. UNKNOWN
EJECTION
A- NOT EJECTED
B- TOTALLY EJECTED
C- PARTIALLY
EJECTED
Y- UNKNOWN
TRAPPED OR
EXTRICATED
A- NOT TRAPPED
B-TRAPPED/EXTRI-
CATED
C- TRAPPED/NOT
EXTRICATED
Y- UNKNOWN
AIRBAG
A- DEPLOYED
B- NON
DEPLOYED
C-NON-DEPLOY-
ED/SWITCH
OFF
D. NOT
APPLICABLE
Y- UNKNOWN
OCCUPANT PROTECTION
SYSTEM USED
A-NONE USED-VEHICLE
OCCUPANT
B-SHOULDER BELT ONLY USED
C-LAP BELT ONLY USED
0-SHOULDER AND LAP BELT
USED
E- CHILD SAFETY SEAT
IMPROPERLY USED
F- CHILD SAFETY SEAT USED
G-HELMET USED
`1- RESTRAINT USE UNKNOWN
INJURY
A- FATAL
B-INCAPACITA-
TING/SEVERE
C-NON-INCAPA-
CITATING/
MODERATE
0-POSSIBLE!
COMPLAINT
E- NO INJURY
DPSSP 31(18 (REV JAN. 2035)
Approved for Release: 2020/01/28 C06838464
Approved for Release: 2020/01/28 C06838464
WRITE APPROPRIATE LETTER IN BLOCK
CONTRIBUTING FACTORS AND CONDITIONS
PAGE I4
0 6
VISION
OBSCUREMENTS
A. RAIN. SNOW, ETC. ON WINDSHIELD
B. WINDSHIELD OTHERWISE
C. VISION OBSCURED BY LOAD
D. TREES, BUSHES, ETC.
E. BUILDING
F. EMBANKMENT
G. SIGN BOARDS
H. HILLCREST
L PARKED VEHICLES
J. MOVING VEHICLES
K. BUNDED BY HEADLIGHTS
L BLINDED BY SUNGLARE
M. DISTRACTED BY NEON LIGHTS
FIELD OF VIEW
N. NO OBSCUREMEMS
Y. UNKNOWN
Z. OTHER ..._
FN
1
OBSCURED
IN
CONDITION
OF DRIVER/PED
A. NORLIAL
B. INATTENTIVE
C. DISTRACTED
D. ILLNESS
E. FATIGUED
F. APPARENTLY ASLEEP/BLACKOUT
G. DRINKING ALCOHOL � IMPAIRED
H. DRINKING ALCOHOL - NOT IMPAIRED
I. DRUG USE � IMPAIRED
J. DRUG USE � NOT IMPAIRED
K. PHYSICAL IMPAIRMENT
(EYES. EAR. LIMB)
Y. UNKNOWN
Z. OTHER
I A 1
N_QN_CDLLISiOB SEQUENCE
A. OVERTURNFROLLOvER
B. FIRE/EXPLOSION
C. IMMERSION
D. JACKKNIFE
E. CARGO/EQUIPMENT LOSS OR SHIFT
F. FELL/JUMPED FROM MOTOR VEHICLE
G. THROWN OR FALLING OBJECT
H. EOUIPMENT FAILURE (BLOWN
TIRE. BRAKE FAILURE. ETC.)
OF EVENTS/HARMFUL EVENTS
S. MOTOR VEHICLE IN TRANSPORT
T. PARKED MOTOR VEHICLE
U. STRUCK BY FALLING. SHIFTING
CARGO OR ANYTHING SET in MOTION
BY MOTOR VEHICLE
V. WORK ZONEJMAINTENANCE
EQUIPMENT
W. OTHER NON-FIXED OBJECT
COLLISION MR Finctgancr
LL TRAFFIC SIGN SUPPORT
MM. TRAFFIC SIGNAL SuPpoRr
RN. OTHER POST, POLE. OR
SUPPORT
00, FENCE
PP MAILBOX
00. OTHER FIXED OBJECT MALL
BUILDING, TUNNEL ETD.)
Yv. UNKNOWN
I. SEPARATION OF MIS
in TRANSPORT
J. RAN OFF ROAD RIGHT
K.. RAN OFF ROAD LEFT
L CROSSED MEDIAN/CENTERLINE
M. DOWNHILL RUNAWAY
N. OTHER NON�COLUSION
C.QUISION WITH PERSON.PLQIQB
k IMPACT ATTENUATOR/CRASH CUSHION
Y. BRIDGE OVERHEAD SI RUCTuRE
Z. BRIDGE PIER OR SUPPORT
V.A. BRIDGE RAIL
BO. CULVERT
CC. CURB
DO. DITCH
BE. EMBANKMENT
FF. GUARDRAIL FACE
151
2nd Y
3rd Y
S
,
Y
I Y
DRIVER
I' 1
DISTRACTION I.Y_ I
A. CELL PHONE
BOTHER ELECTRONIC DEVICE
(PAGER. PALM PILOT. NAVIGATION
DEVICE. ETC.)
C. OTHER INSIDE THE VEHICLE
0. OTHER OUTSIDE THE VEHICLE
RA E. NOT DISTCTED
Y. UNKNOWN-
yEklicLE_Qg_N,EpiEsp_pajEci
O. PEDESTRIAN
P. PEDALCYCLE
0. RAILWAY VEHICLE (TRAIN ENGINE)
R. ANIMAL
CO. GUARDRAIL END
NH. CONCRETE TRAFFIC BARRIER
II. OTHER TRAFFIC BARRIER
Li
_. TREE (STANDING)
KK. UTILITY POLE/LIGHT SUPPORT
1
4th
MOST HARMFUL
- - ,�".
EVENT
VIOLATION
A. EXCEEDING STATED SPEED
B. EXCEEDING SAFE SPEED LIMIT
C. FAILURE TO YIELD
D. FOLLOWING TOO CLOSELY-
E. DRIVING LEFT OF CENTER
F. CUTTING IN, IMPROPER PASSING
0. FAILURE TO SIGNAL
H. MADE WIDE RIGHT TURN
I. CUT CORNER ON LEFT TURN
J. TURNED FROM WRONG LANE
K. OTHER IMPROPER TURNING
L DISREGARDED TRAFFIC CONTROL
M. IMPROPER STARTING
II IMPROPER PARKING
0. FAILED TO SET OUT FLAGS,
P. FAILED TO DIM HEADLIGHTS
0. VEHICLE CONDITION
R. DRIVER CONDITION
S. CARELESS OPERATION
T. IMPROPER BACKING
U. NO VIOLATIONS
Y. UNKNOWN
OTHER
I
Ltii
LIMIT
FLARES
I
MOVEMENT PRIOR TO CRASH r
M

--
t
' 15-
� - .
I
'
A. STOPPED
B. PROCEEDING STRAIGHT AHEAD
C. TRAVELING wRONG WAY
D. BACKING
E CROSSED MEDIAN INTO
K. STOPPED PREPARING TO,
OR MAKING U-TURN
L MAKING TURN DIRECTION
UNKNOWN
M. STOPPED. PREPARING TO
. ENTERING TRAFFIC FROM
SHOULDER
U. ENTERING TRAFFIC FROM
MEDIAN
V ENTERING TRAFFIC FROM
REASON FOR
MOVEMENT
A. TO AVOID OTHER VEHICLE
B. TO AVOID PEDESTRIAN
C. TO AVOID ANIMAL
D. TO AVOID OTHER OBJECT
E. PASSING
F. VEHICLE OUT OF CONTROL
NOT PASSING
G. VEHICLE OUT OF CONTROL
H. FOR TRAFFIC CONTROL
I. DUE TO CONGESTION
J. DUE TO PRIOR CRASH (COLuSIONI
K. DUE TO DRIVER CONDITION
L DUE TO DRIVEN VIOLATION
M. DUE TO VEHICLE CONDITIONZ.
(FAILURE)
N. DUE TO PAVEMENT CONDITION
0. HIGH WIND
P NORMAL MOVEMENT
Y. UNKNOWN
Z. OTHER
I
1.Y1
PASSING
I
OPPOSING LANE
F. CROSSED CENTER LINE INTO
OPPOSING LANE
G. RAN OFF ROAD (NOT WHILE
MAKING TURN AT INTERSECTION)
H. CHANGING LANES ON
MULTI-LANE ROAD
I. MAKING LEFT TURN
J. MAKING RIGHT TURN
TURN LEFT
N. STOPPED, PREPARING TO
TURN RIGHT
0, SLOWING TO MAKE LEFT TURN
P. SLOWING TO mAKE RIGHT
TURN
0. SLOWING TO STOP
R. PROPERLY PARKED
S. PARKING MANEUVER
PARKING LANE
W, ENTERING TRAFFIC FROM
PRIVATE LANE OR DRIVEWAY
X. ENTERING FREEWAY FROM
ON RAMP
Y. LEARN� FREEWAY VIA
OFF RAMP
Z. OTHER OR UNKNOWN
VEHICLE
CONDITION K
A. DEFECTIVE BRAKES
B. DEFECTIVE HEADUGHTS
C. DEFECTIVE REAR UGHTS
D. DEFECTIVE SIGNAL LIGHTS
E. ALL LIGHTS OUT
F. DEFECTIVE STEERING
G. TIRE FAILURE
H, WORN OR SMOOTH TIRES0.
I. ENGINE FAILURE
J. DEFECTIVE SUSPENSION
K. NO DEFECTS OBSERVED
Y. UNKNOWN
Z. OTHER
ALCOHOIJDRUG
INVOLVEMENT
HOL/DRUGS SUSPECTED A
ALCOIT
A. YNEEZHA ELCROAHLOCLOHOL NOR DRUGS
C. YES�DRUGS
YES-ALCOHOL AND DRUGS
Y. UNKNOWN
ALCOHOL B
A. TEST REFUSED
,
TRAFFIC r/4 I
CONTROL
A. STOP SIGN
B. YIELD SIGN
C. RED SIGNAL ON
D. YELLOW SIGNAL ON
E. GREEN SIGNAL ON
F. GREEN TURN ARROW ON
G. RIGHT TURN ON RED
H. UGHT PHASE UNKNOWN
I. FLASHING YELLOW
J. FLASHING RED
K. OFFICER. FLAGMAN
L RR CROSSING, SIGN
M. RR CROSSING,SIGNAL
N. RR CROSSING. NO CONTROL
0. WARNING SIGN (SCHOOL ETC.)
P. SCHOOL FLASHING SPEED SIGN
0. YELLOW NO PASSING LINE
R. WHITE DASHED LINE
S. YELLOW DASHED LINE
T. DIKE LANE
U. CROSSWALK
V. NO CONTROL
Y. UNKNOWN
Z. OTHER
PEDESTRIAN 7
ACTIONS L__ _
A. CROSSING. ENTERING ROAD
AT INTERSECTION
B. CROSSING. ENTERING
ROAD NOT AT INTERSECTION
C. WALKING IN ROAD - WITH
TRAFFIC
0. WALKING IN ROAD - AGAINST
TRAFFIC
E. SLEEPING IN ROADWAY
F. STANDING IN ROADWAY
G. GETTING ON OR OFF OTHER
VEHICLE
H. PUSHING, WORKING ON
VEHICLE IN ROAD
I. OTHER WORKING IN
ROADWAY
J. PLAYING IN ROADWAY
K. NOT IN ROADWAY
Y. UNKNOWN
Z. OTHER
VEHICLE
LIGHTING
C
A. HEADLIGHTS ON
13. HEADLIGHTS OFF
C. DAYTIME RUNNING LIGHTS
V UNKNOWN
B. NO TEST GIVEN -
C. TEST GIVEN. RESULTS PENDING
, .
D. TEST GIVEN BAG IT%
A
A. TEST NOT GIVEN
TRAFFIC
CONTROL E
CONDITIONS
a CONTROLS FUNCTIONING
B. TEST GIVEN, RESULTS PENDING
C. TEST REFUSED
D. DRUGS REPORTED (SPECIFY IN NARRATIVE)
Cl. CONTROLS NOT FUNCTIONING
C. CONTROLS OBSCURED
D. LANE MARKING UNCLEAR
OR DEFECTIVE
AFFIX DLOO--0 ALCO3OL KIT LAUEL HERE
E. NO CONTROLS
Y. UNKNOWN
(OR ENTER BLOOD ALCOHOL KIT NUMBER)
DIRECTION BEFORE CRASH
FINAL LOCATION
OF VEHICLES
DISTANCE TRAVELED
AFTER IMPACT
SPEED
qicpmAR Ic1DATA (FEET)
HEADED
ON HIGHWAY, STREET OR DRIVE
EST.
POSTED
FR
FL RR
RL
'--- -1 NE
f : S W
, 1
2 5
_
DAMAGE TO VEHICLE
AREA DAMAGED
C 05
EXTENT OF DEFORMITY
A. NONE
I I
GIST IA_
LCj1ST ,V,EINFNORMINOR
'H
D. MiNOFVMODERAIE
N. UNDER.
CARRIAGE
/ I
K
2ND T
2ND E- MODERATE
F. MODERATE/SEVERE
0. TOTAL
Q. SEVERE
P. OTHER
0. NONE
Y. UNKNOWN
3RD _ _J
13RD H.VERY SEVERE
V. UNKNOWN
CITATION ND
VEH. PED.
ELS._011.0312,110
0
Do
Do
0
0 0
NOTICE OF INSURANCE VIOLATION 0
DPSSP 3105 (REV. JAN. 20051
Approved for Release: 2020/01/28 C06838464
INVESTIGATING OFFICER'S INMALS