COLLISION REPORT

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 06866676
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 15
• Document Creation Date: March 9, 2023
• Document Release Date: October 30, 2020
• Case Number: F-2017-01888
• Publication Date: June 16, 2017

Approved for Release: 2020/10/30 C06866676
TOTAL NUMBER OF ,
VEHICLES INVOLVED
DATE OF CRASH
PARISH
CI
CRASH
OCCURRED ON
A. INTERSTATE
BUS. HWY
C STATE FAVY
O PARISH ROA()
E. CITY STREET
F OFF ROAD,
PRIVATE PROPERTY
G TOLL ROAD
STANCE
WRITE APPROPRIATE LETTER IN BLOCK
ROAD SURFACE
(ONE PER COLUMN)
A, DRY A. CONCRETE
B WETBLACKTOP
C, SNOW/SLUSH C. BRICK
DICE DORA
E CONTAMINANT
(SAND, MUD V UNKNOWN
DIRT, OIL, ETC.) 2. OTHER
Y UNKNOWN
WEATHER
A. CLEAR
B, CLOUDY
GRAIN
D. FOG/SMOKE
E SLEET/HAIL
F SNOW
G. SEVERE CROSSWIND
H. BLOWING SAND, SOIL,
DIRT, SNOW
Y. UNKNOWN
Z. OTHER
00,00000000000000000000000"
PASSENG
CAR
LT, TRUCK
(RU.. ETC.)
B, C, OR S
WITH TRAILER
VAN PEDALCYC E
AMBULANCE
SERVICE
Central Intelligence Agency
TIME (0000)
MILEPOST
DISTRICT/ZONE TROOP ,
PARISI I CODE -
E
T YS 0
FEET [,,JSE
MILES Ei NE
FEETri SW
ROADWAY NAME
1600029912
STREET/HIGHWAY I AT INTERSECTION NOT AT INTERSECTION
TREErHIG WAY LI AT INTER
ROADWAY
CONDITIONS
'( �
CTIDN 1,:'; NOT AT INTERS 'TION
CONTRIBUTING FACTORS AND CONDITION
A. NO ABNORMALITIES
B. SHOULDER ABNORMALITY
C. HOLES
0, DEEP RUTS
E. BUMPS
E LOOSE SURFACE MATERIAL
G. CONSTRUCTION, REPAIR
H OVERHEAD CLEARANCE LIMITED
CONSTRUCTION NO WARNING
J, PREVIOUS CRASH
K. WATER ON ROADWAY
L ANIMAL IN ROADWAY
M. OBJECT IN FIOADWAY
Z. OTHER
KIND OF LOCATION
A MANUFACTURING Oft INDUSTRIAL
B. BUSINESS CONTINUOUS
C. BUSINESS, MIXED RESIDENTIAL
D. RESIDENTIAL DISTRICT
E. RESIDENTIAL SCATTERED
F, SCHOOL OR PLAYGROUND
G. OPEN COUNTRY
Z OTHER
TIME CALLED
ARRIVED SCENE
TYPE OF ROADWAY
:B
A. ONE-WAY ROAD
B, TWO-WAY ROAD WITH
NO PHYSICAL SEPARATION
C, TWO-WAY ROAD WITH A
PHYSICAL SEPARATION
D. TWO-WAY ROAD WITH A
PHYSICAL BARRIER
Y UNKNOWN
Z. OTHER
RELATION TO
ROADWAY
A. ON ROADWAY
IF SHOULDER
C, MEDIAN
O BEYOND SHOULDER. LEFT
E. BEYOND SHOULDER-RIGHT
F. BEYOND RIGHT OF WAY
G. GORE
Y UNKNOWN
It MOTOR
LB HOME
OTHER
ALIGNMENT
A. STRAIGHT LEVEL
B STRAIGHT-LEVEL ELEVATED
C CURVE-LEVEL
O CURVELEVEL ELEVATED
E. ON GRADE-STRAIGHT
F ON GRADE.CURVE
G. HILLCREST.STRAIGHT
� HILLCREST.CURVE
I. DIP, HUMP-STRAIGHT
J, DIP, HUMP ...CURVE
Y. UNKNOWN
ACCESS CONTROL
A, NO CONTROL
(UNLIMITED AGGLES TO
ROADWAY)
B. PARTIAL CONTROL
LIMITED ACCESS TO ROADWAY
C, FULL CONTROL
(ONLY RAMP ENTRANCE S EXIT)
Y. UNKNOWN
Z. OTHER
VAWENCLOS
BOX
FLATBED
DUMP TRU
TRAFLEE
PUBUC
PAUPER-1Y
UAMAGE
PAGE it
01
.IT
PLI
s PHOTOS
MACIF
'TPAJN FATALITY
LVED
PRIMARY FACTOR
SECONDARY FACTO
A
A. VIOLATIONS
B MOVEMENT PRIOR TO CRASH
C VISION OBSCUREMENTS
D. CONDITION OF DRIVER
E. VEHICLE CONDITIONS
F. ROAD SURFACE
G ROADWAY CONDITION
H. LIGHTING
I. WEATHER
J. TRAFFIC CONTROL
K. KIND OF LOCATION
L. CONDITION OF PEDESTRIAN
M, PEDESTRIAN ACTIONS
AR GO TANK CONCRETE
MIXER
DEPARTED SCENE ARRIVED HOSPITAL
ii
FIRE
DEPARTMENT
[1] RESCUE
UNIT
A.
B,
C.
0.
F.
Y.
Z.
LIGHTING
DAYLIGHT A
DARK NO STREET
LIGHTS
DARK � CONTINUOUS STREET
LIGHT
DARK -STREET LIGHT AT
INTERSECTION ONLY
DUSK
DAWN
UNKNOWN
OTHER
AUTO
TRANSPORTER
OG TRUCK/
TRAILER
REFUSEARBAGL
HOPPER
K 1-4
POLE TRAILER
X Z
NO
CARGO OTHER
BODY
TIME CALLED ARRIVED SCENE
N
INVESTIGATING OFFICER'S NAME (PRINT)
UPSSP 3105 (REV JAN, 2005)
NAME OF AGENCY
,
TIME OF NOTIFICATION
r" I .161(Li _1Ll1
INVESTIGATING
POLICE I A STATE C, PARISH
AGENCY B. CITY Z. OTHER
SIGNATURE
TIME OF ARRIVAL
DATE REPORT COMPLETED
BADGE #
TIME ALL LANES OPENED
SUPERVISOR'S
INITIALS OR BADGE#
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YEAR
STREET ADC,RESS:.
INTERSTATE CARRIER
NAME (LAST, FIRST, MIj
PEDESTR
L
MAK
Central Intelligence Agenc
MAKE
STREET ADDRESS 07303 BEVERLY PARK DR
CITY SPRINGFIELD
STATE CLASS " '
V A
moss IA
STREET ADD RE
COY
TYPE
MENT VEHICLE L
it#,IATVOCINTO
T 6 1 9 4 6 3 72
UPPER BODY
CLOTHING uGHT
T MI OR COMPANY NAME)
AYES REMOVED
VEHICLE , B. NO BY
TOWED N C LEFT AT SCENE
STATE VA
YEAR
AltmoxItu
Wo7wWW NFORMAIESEO
STATE
NAME OE
VACS E
STATE
PAGE #
# TIRES
REASON TOWED
vEocLE DAMAGE
EA�ENER ARRESTED
Z INSURANCE i4OLATION:"-
Z DIRM
NUMBER
TRANSPORTED TO MEDICAL FACILITY
& YES C AFFusED AID
6 NO UNKNOWN N
ELEPHONE
Z(IT
INSURANCE CO. NAME
NOT ACENCY MAUR
AGENT'S FIAMEIADE
POUCY NUMBER
EAPIRATION DAIS
PRONE
OCCUPANT'S NAME (LAST, TI
STREET ADDRESS
CITY
STATE
ZIP
TRANSPORTED TO MEDICAL FACILITY
A YES c REEUStp AD
Ii NO UNKNOWN
NAL�L ,3E
FACILITY
Aar
STREET ADDRESS,
STAT
TRANSPORTED TO MEDICAL FACILITY NAME
TA
A YES C REFUSED ASS , SAER
EASE
OPSSP 3105 REV, AN.
: A-NOT EJECTED A- , EPLOYED
B-TOTALLY EJE r t0; ON
' C-PARTIALLY GATED DEPLOYED
EJECTED PPE T 1 ON-DEPLOY-
Y- UNKNOWN EXTR$CATED .EOISWITCH
UNKNOWN1 OFF
CAR D-NOT
APPLICABLE
i Y� UNKNOWN
A- NONE US A FATAL
OCCUPANT B4NCAPACITA�
B-SHOULDER BELT ONLY USED, TIN/SEVERE
LAP BELT ONLY USED C.NON-INCAPA-
SHOULDER AND LAP BELT CRATING!
USED MODERATE
CHILD SAFETY SEAT D.POSSIBLE)
IMPROPERLY USED COMPLAINT
CHILD SAFETY SEAT USED END INJURY
ELMET USED
SITIAINT USE UNKNOWN
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WRITE APPROPRIATE LETTER IN BLOCK
VISION
OBSCUREMENTS
A RAIN, SNOW, ETC EN WINDSHIELD
WINDSHIELD OTHERWISE Of3SCURED
Ti VISION OSSCWIE 0 DT 6 DAD
0 TREES, BUSHES ETC
E SWIPING
F EMBANKMENT
Ti SIGN BOARDS
PHILCREST
PARKED VEHICLES
MOVING VEHICLES
K�. ammo ISV HEADLIGIKTS
BLINDED ELY SUNDLARE
STRACTE.0 BY NEON LIGHTS IN
YIELD OF VIEW
TI NOOESCUREPAENTE
UNKNOWN
VIOLATION f
XLVEDIKO STATSU SPEED LIMIT
SPEED LIMIT
TO WELD
AL
TRAFFIC
CONTROL
CONTRIBUTING FACTORS AND CONDITIONS
CONDITION
OF DRIVER/PED I
NORVAL
13 INATTENTNE
C. DISTRACTED
iu.NEPTI
E. FATIGGEO
F APPARE,NTLY Alli:EPtRLACKCIL31
O DRINKING ALCOHOL IMPAIRED
H. DRINKING ALCOHOL - NOT IMP IVREO
I OROS USE . sAFKIHEL,
3. DRUG USE . NOT imPAIREII
PHY54DAL IMFAP,NMENT
(EYES, EAT, LASS
UNKNOWN
DRIVER
DISTRACTION
A CELL PHONE
B OTHER ELECTRONIC DEVICE
(PAGER. PALM PILOT PLAin "GAMIN
DEVICE, ETC I
C OTHER INSIDE THE VEHICLE
0 OTHER OUTSIDE THE VEHICLE
E NOT DISTRACTED
Y UNKNOWN
REASON FOR
MOVEMENT
TO AVOID OTHER VEHICLE
O TO AVOID PEOF,STPNAN
TO AVOID ANIMAL
0, TE/ AVOID OTHER OBJECT
PASSING
VEHICLE OUT OP c.onTrolt�
ES NOT PASSING
IV VEHICLE OUT OF CONTROL. PASSING
ITRAPTIC CONTROL
DUE TO OVPA3F5r14
3 DUE TO TRI)R TA
DU:
DUE TO DIAIVLR 1 0155101
VI DL
A STOP SIGN
, YIELD SIGN
RED SIGNAL ON
O YELLOW SIGNAL ON
GREEN SIGNAL ON
GREEN TURN ARROW ON
O RIGHT TURN 014 RED
IA LIGHT PHASE UNKNOWN
FLASHING YELLOW
13 FLASHING RFD
K, OFFICER, FLAGMAN
RN CRos3ING.. SIGN
NI RR CROSSINOSIGNAL
RR CROSSING, NO CONTROL
O WARNING SIGN (SCHOOL, ETC,)
P SCHOOL FLASHING SPEED SIGN
. YELLOW NO PASSING ONE
O INTOTE DASHED LINE
YELLOW DASHEO IJNE
BIKE LANE
U, CROSSWALK
^ NO CONTROL
UNKNOWN
AEl
A
PAN
AL MOTVEMLNT
PEDESTRIAN
ACTIONS
CROSSING, ENTERING ROAD
AT 1141 ERSECTION
CROSSING, ENTERING
ROAD NOT AT INTERSECTION
WALKING IN ROAD - WITH
TRAFFIC
WALKING IN 110141) ACLSIIIT, I
INSTILl
SLEEPIFVIV IN ROADWAY
STANDING ROADWAY
,ET riNci ON OR OFF OTHER
KING ON
AIVWAY
LAYING IN A
T IN ROADWAY
THE
STREET IV
DAMAGE TO VEHICLE
AREA DAMAGED
C TIE
CARRWVE
CP TOTAL
P OTHER
ET NONE
Y. UNKNOWN
2Ntl
EXTENT OF DEEGIRNIrFY
1, NONE
FT VERY MINOR
T C, MINOR
0- TAIAGRoAODEPIAT3
!2ND MODERATE
MODEPLATE/SEVERE
0- sEpEst
WAIN SEVERE
ILTNANOwN
NA
U N
MOTOR VEHICLE
13 ST'T13011llY A
CARGO OR ANYThING SET I
111 VIUTOFI VEHICLE
S 114 NOTE 4OP1fV3FEAITITYVEIARCI
TA OTHER
IT
HCI
AY
191
C�
,YL
1114111141 VI IICLI IRA
A TE MA I.
OMR
14_ WITH_EMEDOBJECT
AITENDATORAIRASH CUSHION
OVERHEAD STRUCTURE
E PIER OF4 SUPPORT
E RAIL
MOVEMENT PRIOR TO CRASH
DING MILL .13141 A
III
AC)
VEHICLE
CONDITION K
A DEFECTIVE EI1155M5
DEFECTIVE HfUTElt IGHTS
C DEFECTIVE REAR LIGHTS
IL OEFIEDTTVE SIGNAL LIGHTS
E ALL LIGHTS OUT
F DEFECTIVE STEERING
C TIRE FAILURE
II wowN oD 55100111 TIDE
ENDINE FAII.VRE
F DEFECTIVE SUITATENSION
K ND DETECTS OPTSEINED
3 UNKNOWN
TING
A HEADLIGHTS UN
13. HEADLIGHT'S or r
C. DAYTIME RuNNING LIGHTS
UTIIINOWN
TRAFFIC
CONTROL
coNDITioNs
CONTPULS FLINCTTANING
otanc Ls NOT ruNCTIONING
ceornot,z OBSCURED
LAVA ABittNID UNqtE.AR
LA CTTVE
15) DOLS
K STOPPED PREPARING TO,
OR MAKING U TURN
L MAKPAG TURN, DIRECTION
UNITNOWN
M STOPPED, MIER:WM:3 TO
IURN LIFT
N STOPPED, PREPARING TO
TURN RIGHT
0 SLOWING TO MAKE LEFT TURN
P SLOWING TO MAKE RIGHT
TURN
0 SLOWING TO STOP
T4 KU:MERLE PARKED
S PARKING MANEUVER
ALCOHOL/DRUG
INVOLVEMENT
A. NEITHER ALCOHOL NOR DRUGS
EL YES-ALCOHOL
C YES-DRUGS
USES-ALCOHOL AND DRUGS
Y. UNKNOWN
A TEST REFUSED
13., NO TEST GIVEN
C., TEST GIVEN, RESULTS PENDING
EL TEST GIVEN, BAG
PP
PAGE #
04
RC SIGN SUPPORT
FIG SWAM. SUPPORT
R POST, POLE, OR
OPT
THEA 1411500EJECT (WALL
UILITING, TUNNEL ETC I
NKNOWIA
1st Y ,Y
2nd Y
3rd Y Y
Y Y
MOST HARMFUL EVE NT
T ENTERING TRAFFIC FROM
SHOULDER
U. ENTERING TRAFFIC FROM
MEDIAN
V ENTERING TRAFFIC FROM
PARKINS LUPE
W MERINO TRAFFIC FROM
PRIVATE LANE OR DRIVEWAY
X ENTERING FREEWAY EFIONI
ON RAMP
LEAVING FREEWAY %ma,
OFF RAMP
Z. OTHER OFT UNKNOWN
A
V. TEST NOT GIVEN
IL TEST GIVEN, RESULTS PENDING
C. TEST REFUSED
DRUGS REPORTED (SPECIE-3 IN NARRATIVE)
TAN TTFIIS\
AlA
CITATION 21C
VEH PED.
r)
ft,Q9QFjp 199
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PAGE a (b)(3)
--
N CARCO CODY TYPE I YEAH
go 1 fc
044 14
STREET ADO
INTERSTATE cont
,
NAME (LAST, FIRST MS OF IXKO
Dal
�
s REP ADDRESS 11016 OUTPOST DR
cive NORTH POTOMAC
STALL CLASS NLX.S.I5EMENFS DPIRLLRS ILENSR MAIDEN
Central Intelligence Agenc
MAKE
MD
PEDESTRIAN ONLY
G D
TELEPHONE a
STATE MD
KO 00 1 1 5 01 5 2 4 7
UPPER BODY
CLOTHING Ltwir,
MODEL
:IT
A YES
- B NO
C LEFT AT SCENE
o
00EES # AXLES # TIRES
REASON TOWED
A VEHICLE (WAAGE
5 055/RS AKALL5rED
C INSURANCE VIOLATION '-
Z. OTHER
NUMBED
�iA LA�.1.6 MA05
TRANSPOITTED TO MEDICAL FACILITY
A. YES C. REFUSED .04) .
(3 NO F UNKNOWN .
OWNER'S NAME (IASI', FIRST, MI OR COMPANY NAME)
ST EFT ADDRESS
Ii
STAVE
ZIP
INSURANCE CO. NAME
AGENT'S NAME/ADDRESS �
POLOC1/ NOWA
EyTMATON DATE
NAME (LAST; FIRST. MS
STREET ADDRESS
CITY ,
ST FIRST ME
STREET ADDRESS
CITY
STALE
STATE
ZIP
ZIP
TRANSPORT ED TO MEDICAL FACILITY RA�,
A YES C REFUSED ND rAc,,r,
8 NO 5 014KNOWN � � �
TRANSPORTED TO MEDICAL- FACILITY '
A. YES C. REFL./ 4E.0 AID
Ft, NO t UNKNOWN
Ait.*
DP "P
V JAN 20
A. NOT EJECTEI A- NOT TRAPPED A- DEPLOYED
A. V A- FATAL.
B-TOTALJ-Y EJE 8- TRAPPED/EXTRI-I B-NON
C-PART1ALLY CATED DEPLOYED
' ELT ONLY USE
BANCAPACITA,
7ING/SEVERE
I EJECTED C-TRAPPED/NOT C.NON-DEPLDY-
LY USED
NON-INCAPA-
Y- UNKNOWN
EXTRICATED I ED/SWITCH
LAP BELT
CITATING/
Y- UNKNOWN I OFF
MODERATE
0-NOT
D-POSSIBLE/
APPLICABLE
COMPLAINT
Y. UNKNOWN
E- NO INJURY
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WRITE APPROPRIATE LETTER IN KOOK
VISION
OSSCUREME
A RANK, SNOW, ETC. ON wiNDSHLELD
0 WINDSHIELD OTHERWISE OCISCuRED
VISION GESCuRED DY LOAD
TREES, EluSHES. ETC
DUILSKNo
VSANKMENT
C SIGNDEIMOS
REST
D VEHICLES
ENICLES
v HEADLIGHTS
SUNGLARE
Y NEON LIGHTS IN
VIOLATION
STATED SPED LIMIT
SAFE SPEED
YIELD
TOD CLOSELY
FT OF CENTER
IMPROPER PASSING
SIGNAL
GNI TURN
NE ON LEFT TURN
El WRONG LANE
H IMPROPER P51110
O EASED
P FNLSDTODIMM
5, CARELESS
IMPROPER
LI NO VIOLET
UNKNOWN
FLARE
A. STOP SIGN
, 'YIELD SIGN
- RED SIGNAL ON
O. YELLOW SIGNAL ON
E. GREEN SIGNAL ON
GREEN TURN ARROW On
LI RIGHT TURN ON RED
IS LIGHT PHASE UNKNOWN
FLASHING YELLOW
l. FLASHING MO
N. OFFICER, FLAGMAN
RR CRosSLNG, SIGN
CROSSING�NONAL
IS FIR CROSSING, NO CONTROL
0 SIGN (SCHOOL, EMI
FLASHING SPEED SIGN
NO PASSING LINE
'IRLEHEG LIME
YELOW DASHED LINE
T SIlKS LANE
F UNIT
CONTRIBUTING FACTORS AND CON
CONDITION
O DRIVER/PED
oPmAL
ATTENTIVE
e
DRIVER
DISTRACTION
A, CELL PHONE
II OTHER ELECTRONIC DEVICE
WAGER, PALM PILOT, NAVIGATION
DEVICE, FTC)
�OTHER INSIDE THE VEHICLE
EL OTHER CuTs4DE THE VEHICLE
, NOT DISTRACTED
, UNKNOWN
, TO AVOID OTHER vEi.spcLE
To Avow PEDESTRIAN
TO AVOID ANIMAL
TOAVCIG OTHER DEJECT
VEHICLE OUT F CONTFAO
11110
TO N C
A, CROSSING, ENTERING Enka)
AT INTERSECTION
IL CROSSING, ENTE,RING
ROAD NOT AT INTERSECTION
WALKING IN ROAD - WITH
TRAFFIC
WALKING IN ROAD AGAINST
TRAFFIC
IL SLEEPING IN ROADWAY
STANDING IN ROADWAY
GETTING ON Oil OFF OTHER
VEHICLE
H. PuSHING, WORKING ON
VEHICLE IN ROAD
OTHER WORKING Fl
ROADWAY
3. PLAYING IN ROADWAy
NOT IN ROADWAY
V. UNKNOWN
OTHER
y,mv4 TO VEI-UCLE
AREA DAMAGED
OF DEFORMITY
Ar, NONE
D. VERY mpiDA
sr C. MINOR
0- ANNOMADOERAPE
KACCEIVIE
MODERATE/SEVERE
SEVERS
HVEAY SEVERE
TUNKNOWN
C CONTROLS I
0 LANE MARKI
On DEFECT
E NO CONTRO
UNANDWN
ILIStON
PPNIVaLLOVER
1051014
IQ ,0rti.PERSiON,,t4t1Tati
E.CULOFF.NON,...fiXEP.0134.ECT
IAN
�
T S
TIE $Y III
0 OR AN
ToR VS
0
MOVEMENT PRIOR TO CRASH
T AHEAD
VEHICLE
CONDITION ,K
A OEFECIIVE BRARES
DEFECTEVE HEADLIGHTS
C. DEFECTIVE RENA OGHTs
DEFIEtilvE En:DIAL LIGHTS
F. LIGHTS COT
F DEFECTIVE. MERINO
0, TIRE FAILURE
H. WORN oPi SMOOTH TIRES
ENGINE FAILURE
DEFEcTINE suSPENSIoN
rk, HQ DEFECTS OKSEMED
5, uNAKEKNN
Z. OTHER ,
VEHICLE
LIGHTING y
A. HEADLIGHT% ON
11 HEADLIGHTS off
C. DAYTIME RuNNwa LIGHTS
LINK NOWN
TRAFFIC
CONTROL
CONDITIONS
TONTIECLIS wtINCIPONNG
LIT FUNCTIONI/A3
RKVRE0
" UNCLEAR
N DISTAN
AFT
F. STOPPED PREPARNG TO,
DO MAKING U-TURN
L MAKING TURN, DIRECTION
UNKNOWN
M� STOPPED, PREPARING TO
TURN LEFT
N. STOPPED, PREpAINNO TO
TURN RIGHT
a SLOWING TO MAKE LEFT TURN
1, SLOWING TO MAKE ROW
TURN
0- SLOWING TO STOP
R PROPERLY PARKED
5, PARKING MANEUVER
ALCOHOL/DRUG
INVOLVEMENT
NEITHER ALCOHOL NOR DRUGS
8. YES-ALCOHOL
C YES-DRUGS
0, YES-ALCOHOL AND DRUGS
Y, UNKNOWN
A, TEST REFUSED
8, NO TEST GIVEN
C TEST GIVEN � RESULTS PENDING
a TEST GIVEN, SAC
A, TEST NOT GIVEN
EL TEST GIVEN , RESULTS PENDING
C., TEST REFUSED
0 DRUGS REPORTED ISPECIFN IN NARRATIVE)
r Ageix Kooe
CITATIONRO
NOTICE Of INSURANCE VIOLATION
YEN PEo
0 0
PAGE 0
06
lilt Y 'Y
2nd YTY
4th
MOST HARMFUL EVENT
S
DPSSP .3ID5 (IEEE JAN. 2035)
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INVESTIGATING OFFICER'S INMALS
Approved for Release: 2020/10/30 C06866676
OFFICER
TM
He
COMPUT CR NUMBER
Central Intelligence Agency
DESCRHe ANY UNUSUAL ORCUMSIANCES ASSMATED WITH CRASH, INCLUDING OFHOEFES OBSERVATIONS AND OPINIONS,
INCLUDE WETNESS NAMES, ADDRESSES PHONE NUMBERS, ETC.
TE DAMAGE TQ P05CCDEIRRIVAT PSRIY LWITh OWNEff511AME &AMAMI& THE EXUDE THE .NARBATUVE,
REFER TO EACH BY VEHICLE NUMBER
On 26 July 2016 Officer Bryan Moore responded to a traffic accident at the entrance of
1500 Tysons Mclean Dr. Upon arrival to the scene of the accident Officer Moore made contact with
both drivers. Vehicle 1 was a Honda Accord, license plate WBE-3370 operated by Damon Bogger,
traveling in the right lane headed inbound to Liberty Crossing. Vehicle 2 was a blue Honda
Fit, license plate 78L4609 operated by Chongho Ko, traveling in the left lane headed inbound
to Liberty Crossing. Based on driver statements and the scene I, along with supporting officers,
determined that vehicle 2 failed to maintain control of his vehicle and side swiped vehicle 1. I
observed damage to the right side front passenger door of vehicle 2, and I observed damage to the
front bumper of vehicle 1. The driver of vehicle 2 was reluctant to supply proof of insurance after
multiple requests by myself and supporting officers on scene. Both drivers completed a
driver exchange form and a warning was issued to the driver of vehicle 2 for afceFailure to
maintain control of vehicle.fif No injuries were reported and no EMS was called to the
scene.
3110 (NOV. JAN, 200S)
iNVESIIGAIING OFFICES'S OlmALS
PAGE #
�0 7
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Datrand Time ofOilense
4,
Place of Offense L.,17,4
Offense Description
Febi
veh
Defendant's Last Name
Street Address
Driver's Licebse No.
Velez
Vehicle Tag No,
dlbL
Year
loir om
4480W
Vehi
8/cfn
Collateral (fine)
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OFFICER NAME:
core,
REPORT NO:
�
LOCATION (STREET/INTERSECTION/ROUTE NO.)
5 ean r
VEHICP'EARon bcf VEHICLE MAKE
OPERATIONS BRANCH
INGTON, D.C. 20506
Hondo1/4
DATE:
7/4
TIME:
3
VEHICLE MODEL
VEHICLE'S PLATE (TAG) NO. 7
DRIVER OF VEHICLE
DRIVER'S LICENSE NO.
�POO� 115
HOME PHONE (
EXPIRATION MONTH/YEAR
STATE HD
vo
STATE koi rs,
oei-L RA6)110,
DRIVER'S ADDRESS (INCLUDE STREET, CITY, STATE & ZIP CODE)
(k) outptc- Dr
&AD t-o
WORK PHONE (
) 70)
DATE OF BIRTH (Month/Day/Year)
OWNER OF VEHICLE ,c-o
47
0 4
INSURANCE COMPANY �
Ld9P-
POLICY NUMBER tko
00
-7
cte
OWNER'S LICENSE NO.
K--000
STATE
HOME PHONE (
WORK PHONE (
OWNER'S ADDRESS (INCLUDE STREET, CITY, STATE & ZIP CODE)
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OFFICER NAME:
REPORT NO:
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DRIVER EXCHANGE FORM
LOCATION (STREET/INTERSECTION/ROUTE NO.)
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VEHICLE YEAR VEHICLE MAKE
VEHICLE'S PLAT
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Approved for Release: 2020/10/30 C06866676
Classify as Appropriate
Name (Last, First, Middle)
BADGE NUMBE(
SECURITY PROTECTIVE SERVICE - Washington, D.C. 20013 [phone]
COMPLAINANT/WITNESS STATEMENT 1 REPORT NUMBER
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Approved for Release: 2020/10/30 C06866676
Classify as Appropriate
SECURITY PROTECTIVE SERVICE - Washington, D.C. 2001 [phone]
COMPLAINANTNVITNESS STATEMENT
WITNESSING OFFICER:
Date. Signature
DRESS:
REPQIT NUMBER
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T ThE INFORMATiON CONTAINED IN THE ABOVE STATEMENT IS TRUE
AND CORRECT.
REPORTING OFFICER:
Date: Signature
Classify as Appropriate
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Approved for Release: 2020/10/30 C06866676
Closed Incident Report
Incident Date/Time: 07/26/16 - 16:21:08
Complaint Oper: MBOBROW,DP026
Incident Number: 000115
How Reported: 5, (P)
Police Inc? Y Date:07/26/16 Time:16:21:08 Dispatcher: NBOBROW,
Police Dist: LX
Cm: , Um: 0000,
Jurisdiction: 01
Dispatch Addr: 1500 TYSONS MCLEAN DR
Incident Type: TCNIP=TCNI(TRAFFIC COLLISION NO INJURIES)
Callers Name:
License #:
E-911 Address:
E-911 Phone #: [phone]
Corrected Addr:0
Entered As Intr: T Emergency AgenciesP
POLI
CE
Close
Type:
N N,5 Routing
Stage:
DP-000
Incident Type:
TCNI
Begin
Time:
162035 Pending
Time:
162108
Recall Time:
162108
Assign
Time:
162108 Scene Time:
162108
Close Time:
172111
Dispo Code: 0 LM44 :CU, No Dispo EgnipmentReport. Number:
Disp Seq: 200400
Eqp-No Sts Aloc AsCvn
Sft
LM44 PD W
20160726-PD 000125
2016-PD00029912
Asgn-Dte Tme ER-tme AS-Tme Off-Idl Off-Id2 Sft
Tran-Dte Tme Arvl-Dte Tme Avil-Dte Tme
201607 162108 000000 162108 BMOORE 2,Pmy
000000 0 000000 0 172111
>CP< LX
P >IC< P.TRAFFIC COLLISION NO INJURIES
--DISPATCHER REMARKS--
P MD DL K000115015247
P MD TAG 7BL4609 / NEG WANTS WARRANTS TMU
P NEG WANTS WARRANTS TMU ON DL
P VA DL T61946372 / VA TAG WRF3370
P NEG WANTS WARRANTS TmU ON INDIVIDUAL OR vsHicLE
P W170391 SHIELD 1041
P POLICE INCIDENT CLOSED BY LZYLSTRA @ POSITION
Call Unit History Log:
Additional Info:
Wrecker Requested:
Coroner Requested:
NCIC Name
NCIC Licence No:
NCIC Hit:
162108
160726/162109/DP026,MBOBRC
160726/162126/DP026,MBOBRC
160726/162139/DP026,MBOBRC
160726/162301/DP026,MBOBRC
160726/162626/DP026,MBOBRC
160726/172101/DP034,LZYLSU
DP034 160726/172111/DP
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Arnie L. Parker
From:
Sent:
To:
Subject:
Signed By:
Luis M. De Pena
Friday, June 16, 2017 9:33 AM
Arnie L. Parker
TCNI
Classification: UNCLASSIFIED
(U) VEHICLE COLLISION NO INJURIES: The SOC was notified of a Vehicle Collision at the Main Gate, Liberty Crossing (LX).
At approximately 1620 hours, Officer Moore, LX, responded to an Uber driver (SUBJECT 1) who, while operating a privately owned
vehicle (VEHICLE 1), struck a privately owned vehicle (VEHICLE 2) owned by an Agency visitor (SUBJECT 2). Damage to VEHICLE 1
consisted of dents and scratches to the passenger's side front bumper, fender, and door. Damage to VEHICLE 2 consisted of a
dislodged front bumper. At approximately 1630 hours, Officer Moore took three photographs of the damage, had SUBJECTs
complete SPS Complainant/Witness Statements and Driver's Exchange Forms, and the scene was cleared without further incident.
A copy of the above information will be forwarded to C/ESG. The following individuals were notified: Shift Supervisor/LX and Shift
Supervisor/SOC. Reference SPS DATAFORCE REPORT #16-29912.
Sgt. De Pena
SOC Day Shift Supervisor
Classification: UNCLASSIFIED
1
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GORDON�FEINBLATT.
ATTORNEYS AT LAW
ROBERT W. KATZ
410.576.4287
FAX [phone]
[e-mail]
Security Protective Service
Washington DC
Email: [e-mail]
Re: Our Client:
D/Accident:
Time:
Report No.:
Location:
Dear Sir/Madam:
233 EAST REDWOOD STREET
BALTIMORE, MARYLAND 21202-3332
410.576.4000 FAX [phone]
WWW.GFRLAW.GOM
September 14,2016
Chong Ho Ko
7/26/2016
3:55 PM
16-29912
Tysons McLean Dr
*NOT ADMITrED IN
VIRGINIA
Please be advised that this office represents Mr. Ko in a claim regarding injuries and
damages as a result of an automobile accident which occurred on the above-date.
Please consider this letter as authorization to release a copy of the above-referenced
police accident report to Frank Bevacqua.
SUITE 300
6701 DEMOCRACY BOULEVARD
BETHESDA, MD 20817
301 . 470 . 7201
POLICE1 1 DOC
11/9/00
Very truly yours,
Gordon Feinblatt LLC
By:
INTERNATIONAL SQUARE C ENTER
1825 I S MEET, NM., SUITE 400
WASHINGTON, D.C. 20006
202 . 659 . 0555
surrE 500
8300 130014E BOULEVARD
'MONS CORNER, VA 22182
800. 713 . 7207
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