Laserfiche WebLink
County <br /> <br />ICity, Township, or Village <br /> <br />Section Number <br /> <br />I <br />I <br />I <br /> <br />i <br /> <br />Type of Terrain <br />r--I Lake or Stream <br />~ Road Right-of-Way <br />C2 Railroad Right.f-Way <br />~ Other (Describe) <br /> <br />Private Marked Trail <br />Governmental Marked Trail <br />Private Unmarked Property <br /> <br />Within City or Village Limits <br />Government Unmarked Property <br />Outside City or Village Limits <br /> <br /> Light Heavy Blowing <br />Weather [] Clear [] Cloudy [] Rain or Sleet [] Fog [] Snow [] Snow [] Snow <br />[] Other contributing factors <br /> <br />Light Conditions ~ Daylight U2 Dawn F-'-I Dusk F'-I Dark <br /> <br />Type of Accident <br />[;32 Struck Fixed Object I---I Collision with Train <br />I--I Machine Rollover F'-I Machine-Car Collision <br />~ Broke through Ice U3 Equipment Malfunction <br />~ Barbed Wire or Fence f---1 Stuck Guy Wire or Cable <br />CD Operator Injured in Mechanism of Machine <br />1523 Equipment Malfunction (describe) for Vehicle gl or/]2 <br /> <br />r--'l Machine-Machine Collision ~ Excessive Speed <br />~ Operator thrown from Machine ~ Loss of control <br />fi-1 Passenger tkrown from Machine <br />U2 Passenger thrown from Object being towed by Machine <br />t---1 Clothing Caught in Machine <br /> <br />Did this accident involve the use of alcohol or drugs? <br /> Operator gl © Yes <br /> <br />Was chemical test taken? <br /> 1 ,~.~ Yes Operator 2 [5221 Yes <br /> Operator <br /> No ~ ~ No <br /> <br />[-~-[No ]B'^'¢ [Operator#2 [~Yes["---~No <br /> <br />Estimated speed at the time of accident: <br /> <br />MPH <br /> <br />Describe accident in detail explaining cause. <br /> <br />Draw an example of machines travel and collision. Mark <br />machines #1 & ~-. Place an arrow in box showing north. <br /> <br /> <br />