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<br />State of Nebraska <br />NEW <br />TRACS KEY NO. <br />Investigator's Motor Vehicle Crash Report <br />L <br />Sheetof <br />16 <br />LOCAL NO./ DISTRICT:AGENCY CASE NO.PHOTOGRAPHS TAKEN?INVESTIGATION MADE AT SCENE? <br />TOTAL NO. <br />1 <br />CENTL21031656 <br />OF VEHICLES <br />YESNOYESNO <br />SMTWTHFS <br />M M / D D / Y Y Y YTIME OF <br />TIME OF <br />DATE OF <br />03/20/202100:3500:45 <br />CRASH <br />ROADWAY <br />CRASH <br />(Military Time) <br />CLEARANCE <br />SECONDARY? <br />COUNTYCITY <br />LATITUDE <br />PLACE OF <br />HALL <br />040.9021794 <br />YESNO <br />CRASH <br />PRIVATE PROPERTY? <br />LONGITUDE <br />ROAD ON WHICH <br />STREET/ <br />CO RD 24 <br />-098.4740142 <br />YESNO <br />HIGHWAY NO. <br />CRASH OCCURRED <br />NSEW <br />FEETOF MILEPOSTHIGHWAY NO. <br />DISTANCE FROM <br />MILEPOST <br />IF NOT AT INTERSECTION <br />IF AT INTERSECTION <br />NSEW <br />NAME OF INTERSECTING ROADWAYOF NEAREST STREET, BRIDGE, RAILROAD CROSSING <br />FEET <br />32 <br />W STOLLEY PARK RD <br />MILES <br />IF CRASH WAS OUTSIDE CITY LIMITS, INDICATE DISTANCE FROM NEAREST TOWN <br />NSEWNSEW <br />MILESOF NEAREST CITY OR TOWN <br />AND <br />2.00 <br />0.00GRAND ISLAND <br />MILES <br />CRASH DATA <br />DOES CRASH INVOLVE DAMAGE TOWORK ZONE <br />CONTRIBUTING CIRCUMSTANCES – <br />TYPE OF INTERSECTION <br />NEBRASKA DEPT. OF TRANSPORTATIONWas the crash in a construction, <br />ROADWAY ENVIRONMENT <br />Number of Approaches <br />PROPERTY?maintenance or utility work zone, <br />YESNO <br />01 - Not at Intersection(up to 2 choices) <br />or was it related to an activity <br />02 - Two (2) <br />00 - None <br />02 <br />01 <br />within a work zone? <br />03 - Three (3) <br />RELATION TO JUNCTION01 - Absence of Sidewalks <br />01 - Yes <br />04 - Four (4) <br />02 - Animal(s) <br />Within Interchange Area? <br />02 <br />02 - No <br />02 <br />05 - Five or more (5+) <br />03 - Prior Crash <br />01 - Yes <br />99 - Unknown <br />04 - Prior Non-Recurring Incident <br />02 - No <br />Overall Intersection Geometry <br />05 - Backup Due to Regular Congestion <br />99 - Unknown <br />Workers Present? <br />01 - Angled/Skewed Y <br />06 - Debris <br />01 - Yes <br />02 - Roundabout/Traffic Circle O <br />07 - Glare <br />Specific Junction Location <br />02 - No <br />03 - Perpendicular + or T <br />97 <br />08 - Obstructed Crosswalks <br />97 <br />00 - Non-Junction <br />97 - Not Applicable <br />97 - Not Applicable <br />09 - Non-Highway Work <br />01 - Acceleration/Deceleration Lane <br />99 - Unknown <br />Overall Traffic Control Device <br />10 - Obstruction in Roadway <br />02 - Crossover Related <br />Type of Work Zone <br />01 - No Control <br />11 - Related to a Bus Stop <br />03 - Driveway Access or Related <br />01 - Intermittent or Moving Work <br />02 - Signalized <br />12 - Road Surface Condition <br />04 - Entrance/Exit Ramp or Related <br />02 - Lane Closure <br />97 <br />03 - Stop - All Way <br /> (wet, icy, snow, slush, etc.) <br />05 - Intersection or Related <br />03 - Lane Shift/Crossover <br />00 04 - Stop - Partial <br />13 - Roadway Width Restricted <br />06 - Railway Grade Crossing <br />04 - Work on Shoulder or Median <br />05 - Yield <br />14 - Ruts, Holes, Bumps <br />07 - Shared Use Path or Trail <br />97 - Not Applicable <br />97 - Not Applicable <br />15 - Shoulders (none, low, soft, high) <br />98 - Other Location (median, <br />97 <br />98 - Other <br />16 - Toll Booth/Plaza Related <br /> shoulder or roadside) <br />99 - Unknown <br />WEATHER CONDITIONS <br />17 - Traffic Control Device <br />99 - Unknown <br />(up to 2 choices) <br />18 - Traffic Incident <br />Location of the Crash <br />01 - Blowing Sand, Soil, Dirt <br />19 - Visual Obstruction(s) <br />03 <br />01 - Before Work Zone Warning Sign <br />ROADWAY SURFACE CONDITION <br />02 - Blowing Snow <br />20 - Weather Conditions <br />02 - Advance Warning Area <br />01 - Dry <br />03 - Clear <br />21 - Work Zone <br />03 - Transition Area <br />02 - Ice/Frost <br />04 - Cloudy <br /> (construction/maintenance/utility) <br />04 - Activity Area <br />03 - Mud, Dirt, Gravel <br />01 <br />05 - Fog, Smog, Smoke <br />22 - Worn, Travel-Polished Surface <br />05 - Termination Area <br />04 - Oil <br />06 - Freezing Rain/Drizzle <br />98 - Other <br />97 - Not Applicable <br />05 - Sand <br />97 <br />07 - Rain <br />99 - Unknown <br />98 - Other <br />06 - Slush <br />08 - Severe Crosswinds <br />99 - Unknown <br />07 - Snow <br />09 - Sleet or Hail <br />MANNER OF CRASH / COLLISION IMPACT <br />08 - Water (standing, moving) <br />Law Enforcement Present <br />10 - Snow <br />09 - Wet00 - Not a Collision Between <br />01 - Officer Present <br />98 - Other <br />98 - Other <br /> Two Motor Vehicles <br />02 - Not Present <br />99 - Unknown <br />99 - Unknown01 - Angle <br />00 <br />03 - Only Law Enforcement Vehicle <br />02 - Front-to-Front <br /> Present <br />LIGHT CONDITION <br />ROADWAY SURFACE03 - Front-to-Rear <br />97 - Not Applicable <br />01 - Daylight <br />0497 <br />04 - Rear-to-Rear <br />01 - Asphalt <br />99 - Unknown <br />02 - Dawn/Dusk <br />05 - Rear-to-Side <br />02 - Brick <br />03 <br />03 - Dark-Lighted <br />06 - Sideswipe-Opposite Direction <br />03 - Concrete <br />SCHOOL BUS RELATED <br />00 <br />04 - Dark-Not Lighted <br />07 - Sideswipe-Same Direction <br />04 - Dirt <br />00 - No <br />05 - Dark-Unk. Lighting <br />98 - Other <br />05 - Gravel <br />01 - School Bus Directly Involved <br />98 - Other <br />99 - Unknown <br />98 - Other <br />02 - School Bus Indirectly Involved <br />99 - Unknown <br />99 - Unknown <br />99 - Unknown <br />PROPERTY <br />OBJECT DAMAGEDOWNER NAMEADDRESSPHONEAPPROX. COST OF DAMAGE <br /> , <br />OBJECT DAMAGEDOWNER NAMEADDRESSPHONEAPPROX. COST OF DAMAGE <br />NAMEADDRESSPHONE <br />WITNESS <br />NAMEADDRESSPHONE <br />OFFICER NO.TROOP/TEAM/BEATDEPARTMENT <br />HALL COUNTY SHERIFF'S OFFICE <br />90832 <br />(Print or type)DATE OF REPORT <br />INVESTIGATOR NAMEINVESTIGATOR SIGNATURE <br />APPROVED BY MARK DREHER <br />MARK DREHER <br />03/20/2021 <br />NDOT Form 40, September 2020 <br /> <br />