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County <br /> <br />Type of Terra/n <br />u-'l Lake or Stream <br />CSig. Road Right-of-Way <br />~ Railroad Right-of-Way <br />r-~ Other 0Descr/be) <br /> <br />City, Township, or Village <br /> <br /> ~ Private M~'ked Trail <br /> I--'1 Govern.mental Marked Trail <br /> t--"l Private Unmarked Property <br /> <br />Number <br /> <br />122 Within City or Village Limits <br />'[Z~ Government Unm~'ked Property <br />I'--1 Outside City or Village Limits <br /> <br /> Light Heavy Blowing <br />Weather [] Clear ~. Cloudy [] Rain or Sleet [] Fog [] Snow [] Snow '[--I Snow <br />[] Other contributing factors <br /> <br />Light Conditions r--1 'Daylight ~ Dawn r--'! Dusk Dark <br /> <br />yp e of Accident <br /> Struck Fixed Object CZZ1 Collision With Train <br />[ZZi Machine Rollover [522 Machine-Car Collision <br />~-1 Broke th.rough rce U-1 Equipment Malfunction <br />r-'--1 Barbed Wire or Fence r---i Stuck Guy Wire or Cable <br />~ Operator Injured in M'echanism'of Machirie <br /> [ZZt Equipment Malfunction (describe) for Vehicle gl or//2 <br /> <br />U=l Machine-Machine Co[Iision r--'l Excessive Speed <br />C~.' Operator thrown from Machine r"'-I Loss of control <br />C--l' Passenger thrown from Machine <br />r--'l Passenger thrown from Object being towed by Machine <br />r--'l Clothing Caught in Machine <br /> <br /> Ope, ator':es No eX,, L Operator S o_ [--1 Yes [] No <br /> <br />Was chemical test taken? <br /> Operator 1 C---l~ts.~ANoyeS Operator '~_ [Z~ ~oY~ Estimated speed at the time of accident: ~_~ ~- ~/0 MPI--I <br /> <br />Describe accident in detail explaining cause. <br /> <br />Draw an example of machines travel and collision. Mark <br />machines #1 & #2. Place an arrow in box showing north. <br /> <br /> <br />