8/18/2019 2015 - August 24 - MDOT Trunkline Evaluation
1/5
Trunkline Evaluation
Location Information RevieweRoadway: Segment Intersection
Signalized Unsignalized D
Curved Straight 2-Lane2-way Multi Lane
Divided Freewa
Control Section: PR Number: Ro
CS BMP: PR BMP: Intersectin
CS EMP: PR EMP:
Good Fair
ct on
Needed No Act
Roadway Condition
Notes
28051 992703
3.83 0
The pavement is in good condition.
CLEAR FORM
8/18/2019 2015 - August 24 - MDOT Trunkline Evaluation
3/5
I T I Z E D
S A N I T I
Z E D
Unit Number
02Unit Known
YesState Driver License Number
MI #############Date of Birth (Age)
##/##/#### (57)License Type Endorsements
Operator CycleChauffer FarmMoped Recreation
Sex
MTotal Occup
02
Unit Type
MVDriver Information
############################################################WILLIAMSBURG,
MI 49690 (###) ###-####
Injury
KPosition
01Restraint
10Hospital
MUNSON MEDICAL CE
Driver Condition
1 2 3 4 5 6 7 8 9 99
Interlock
NoEjected
YesTrapped
Airbag Deployed
Not EquippedAmbulance
KINGSLEY AREA EMG
AlcoholYes No Refused Not offered Test Results
Test Type Field PBT Breath Blood Urine
DrugsYes No Test Results
Test Type Blood Urine
Cit
Vehicle Registration
###########State
MIInsurance / Policy #
##############################Towed To/By
NICKERSONSSpecial
0
VIN
#################VehicleDescription
Make
BMWModel
K1200LTColor
SILYear
2003
Location ofGreatest Damage 01
First Impact
01Extent ofDamage 7
Driveable
NoVehicle Direction
NVehicle Use
01 - PrivateAction Pr
01 - G
Sequence ofEvents( indicates MOST harmful event)
First
17 - Motor veh in transportSecond
Third
U
N
I T / D
R
I V
E
R
Passenger Information
############################################################WILLIAMSBURG,
MI 49690 (###) ###-####
Date of Birth (Age)
##/##/#### (50)
Sex
F
Position
07
Restraint
10
Hospital
MUNSON MEDICAL CEInjury
KAirbag Deployed
Not EquippedEjected
YesTrapped
Ambulance
KINGSLEY AREA EMG
Passenger Information
Date of Birth (Age)
Sex
Position
Restraint
Hospital
Injury
Airbag Deployed
Ejected
Trapped
Ambulance
Passenger Information
Date of Birth (Age)
Sex
Position
Restraint
Hospital
Injury
Airbag Deployed
Ejected
Trapped
Ambulance
Passenger Information Date of Birth (Age) Sex Position Restraint
Hospital
S E N G E R S
