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County <br /> <br />ICity, Township, or Village <br /> <br />Section Number <br /> <br />Type ot Terrain <br />~ Lake or Stream <br />~-n Road Right-of-Way <br /> F-'I Railroad Right-of-Way <br /> r'~ Other (Deecr/be) Crx~ ~-~ <br /> <br /> ~ Private Ma~ed Trail <br /> F--1 Governmental Marked Trail <br /> <br />/[=D Private Unmarked Property <br /> <br />~ Within City or Village Limits <br />,,r-'l Government Unmarked Property <br /> r-'l Out.side 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 ~'~ Dawn ~ Dusk UD Dark <br /> <br />Type of Ace/dent <br />~ Struck Fixed Object [252 Collision with Train <br />["-3 Machine Rollover ~ Machine-Car Collision <br />F-1 Broke through Ice F--I Equipment Malfunction <br />~ Barbed Wire or Fence U2 Stuck Guy Wire or Cable <br />r--1 Operator Injured in Mechanism of Machine <br /> ~ Equipment Malfunction (describe) for Vehicle gl or <br /> <br />r"-I Mach/ne-Machlne Collision r~l Excessive Speed <br />[52 Operator thrown from Machine UE] Loss of contro! <br />~2 Passenger thrown from Machine <br />C2 Passenger thrown from Object behag towed by Machine <br />r--I Clothing Caught in MaChine <br /> <br />Did this accident involve the use of alcohol or drugs? <br /> Operator #1 [] Yes <br /> <br />Was chemical test taken? <br /> Operato i [:71 Operator <br /> <br /> I B.A.C l <br />[] No C, erato 2 [] [] No <br /> <br />IB.A.C. I <br /> <br />IEstimated 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 />