. WW‡‡Citanwa. Aulhardy
10D Control #
.
Supervisor's
AccidentfC†ltne3twëstigation
Report
TA OA . DMalon/Depot/Facl(ity
/Ú
Date of Report ._3___[Briet# BusNohicio #
W2-LM
Day Acoldent Date /27
/ Time /ZQ-7
. HouroPass/PR Operator/Em l.
#
o DOA_Z_JC
2-c*JBadge-
RDOBegIonjng of Work Day (F.Irstplace of work ImrnediatelyfoUowlog0continuous hous off. locludo any XPC, DBL COA elo.woMod, If appHoablo), Operator's Work Houm Pr or to the Inoldent d 7/
1
Proble? YesStudent? Ws instructor's Pass/PR # Assigned Route Run 3
R
Operating Route ( . fdf¼ntkornpict«dmut¢Destinat on c9
Mc
Stroot OnStreet At Icrosssn
_
/Ä At intersection? Yes / ff not at an Intersection, Between ... v and _}_ (straec. Circ e: Near, Far, hd-block rminus, Other Enwronment: r Rain, Snow, Sun Glare, Fog : High Winds, Overoast, . HallStreet Conditions Wet, Black Ice, Flooded Leaves, Mud, 08, Ice, Sand, Other
Pavement Conditions t Slfppery Pothole, Construction Plates. Unovon, Grooved, Manhole Cover
Grade;(L wo,HI Up Hill, Other street Typ 6rldge Grate, Brick Fooe, Cement, Gobblestone, Other Ushting: Ighr'Dark, Sunrise, Elect. Ughting, Dusk Bus Stop Area? Yes / Stop Location: Far, - Near, Mid-lMock Stop Cond t on: GoededMaeksde-. Broke4Curb, No-Curb, Br n sunwarg, nM,
Mu‰
Petbotor.-Unpave&, Snewr- Ace Buc/NYCŸVehicto: (VehIole #f) Ucenso Plate #6
77
Damage: Extonelve, Moderatet Sil(1ht, None, (Ff0 Type (Circle uf Wuck, Auto Make # CustomeàLL # Cust. hýurles _./_.._, SO/Driver In) Y # Oth. Emp InhT-2Pomt F ·G H 7 8 S - Politt . 7 -8. .
A
Pomt 7 8of E ûHTIC 6
BUS 0 M 6 0
W
8 TRUCK 0Intpact D Ul£ED 5 , 1 Impact 5 . T lUCK ... 1 Impact 5
BCE C B A 4 3 2 ifëllicit --' 4 8 2 Vetticle---'. 4
. Action of NYCT Vehlole: Changing Lanos, Leaving Bus Stop, Standing et Bus Stop / at Ught / in Traffic, Rirning Right / Left, Rovers Delay to Servioo 20 P3t.6 Dafay to Bus / Z7 /W/ hy Bus Status: 'BIS, TOV6 Impounded Spare
Status Changed by: B0, R80, 800, OSS, MGR, SUPT, POUCE, PTSB Replacornout Pass/PA # 220 2-f/C . Vehicle- #2: Auto, Veil, 890, Bicycle, Motorcycle, buck LIoonse PI to _ Sta NYCT Whlote? #
Damage to Vehlofo #2; ExIonolve, Moderate, S(Ight, None, A upants 0noWdIntfdriver) # injudos _
Action of Vehic[o #2:. Changin0 Lanes, Moving from Curb, Rbve 6, ing Elg crGift Passinn Right or Left, U-turn Left at alght, Moving Straight Vehicle #3: Auto, Van, 60s, Bicycle. Motorcycle, Truck Uc late # . . State
Damage to Vehicle #3: Extensive, Moder , Slight, P w N/A . # Occupanto Oncluding driver) # !‡r!es
Action of Vehicio #3: Changing Lenoer Moving fropy urb, Reverse Turning RIght or Left, Pusing Right or Lch, U-tum Le(Lor Bight, Moving Straight · IF THE VEMICLE FLED THE SCENE, FILL IN ALL ABOVE INFORMATION INCLUDING A VEHICLE DESCRIPTION BELOW Yehicle Fisd $cone (Doecrlpton): Auto, Van, Bue, Blpycle, Moto ye Ucit
Lde
Plate StateVobloto color ________ Modef/Make/Your eacdptio (Cornpany Logo or Othor) Distinguishfng C.haractertstles
INFORMATION OF THE .OTHER VGiICLÈ (If more than or½ vehicle was inv ed, use addNlenal
fermeF~-. Name of Driver _.
____..__
Address of Driver .
)
Driver's Liconso # _ __.. State issued Male Female ..._ Exp. Date
NEdila Of OWA60 me Plul $
Address o[ Owner
Voh(cle Color
__
Model ____. Make YearNanm/Number of insunirx.3 C2pu ._______.._______ Pejley
.
Supervisor's
Accident/Crime
Investigation
Report
TA OA 00po
6
Date of Accident Day Time Hour laopomtor/Emp ff Pass)P Route RUn
Emt Att. f/ O . Hoapital:
PRG
oua comeEmt Att. N ... Hospitalt__.__ FPN ,_..- , Eng SUS CR M NFORMATION Desorlplion andValoo of PropertyTaken .- ..___ .. .... .
Porpetrator information
Approx, Age Sox Rece Holght sight ______ Chamoteristics
CloWng the Perpolrator wa6 Wearing .__ - .
. Operator/Grnpl. Can Iden0ty? Yo9 / No
Cuatomer Action: Mohted Front/ Rear, Boarding Front /Reer, Ronnlo Sitting, Rear B(sing. N/A Po doS(rian ÂCtfon: In 6treet, Ruruling, Skating, Walking, Biking,
On Sceno (CIrch Yesor Noy PTSB: Yes / OSSI Yes tf BST: Yes / Name (c) and Office
{e)_
. .Other Departmental Intonnation Phone No. Fe× No.
. Con.sole Coffod: fÞ/ No Codrof Deck Ca od: / No. Control Desk Mgn e 7 (namatpacev) Titac Houre Dato Reco{wfd Ot AcCldontDock_ Time Received at ACC Deñk
12
Hours e supt/Leupv/etoAt Sceno 35MM Photos Takon7 Yos / Reported to ACC Dosk SLo . 300 Pass/PR
How was Information Obtained? 4 f .. e /^#Ó6 __.... T me.12 Hours
Employee Witness? Yos/b Nama (print) s goeture Pass/PRR DO _A
NVEST(GATION (Attach additioMI forms {(naaded)
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.Metropolitan Transportation Authority NYCT Department of Buses
MTA Bus Company Long Islancf Bus
DATE:
TO:
fa
FROM:
RE:
Supervisor's
Accident/Crime
Investigation
$4eport
TAOOAO Depot T Date of Accident.1/ZE72d DayÊded Time:/f±gHours VehIcle #:
h-Operator/Empl.
4
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Pass/PR #: .3-.0.E
Route:D
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Run:.I11
sus
vehicio f
NJURED
INFORMATIONPedesirlan .
L] Name )) )%\
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Birth DateF
/ / /f~f
SoxD
. ÉMS #
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Address L
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City /4///r State ZIp Code / / t+ 2f.Hospital . Injury to (bodypart) c)
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Name Birth Date x EMS #Address ____ City Zip Code
Hospital injury to ( ody p rt .
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Name Birth Date / GoEMS #
Address City . Zip Code
Hospital . Injury to (b y par
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Name Birth Date / / , ex EMS #Addroes ._.._ ____ Clty e ZIP Code
Hospital Injury to (body part} ...
OO
Name Birth Date / // a EMS #Address City e P Code
Hospital Injury to (body n
00O
Name Birth Date / / . sed
EMS #Address City_ o ZIp Code
Hospital / . Injury to (body pa t)
GOMPLAINANT
VICTIM/WITNESS INFORMATIONOOO
Name .Phons #'s: Home ( ) . )ðtork ( )Complainant D Witness Age Male O Fe aWD i¾ce
Address City State . Zip Code
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gg
Name_
. P n #8. omo ) WorK ( )Complainant O Witness O Age . Male O Female O Race
Address City . State Zip Code
Name
___
Phone #'e: Horoo ( ) . Work ( )Complainant D. Witness . . Age Male D Female D . Race .
Address....___ City State Zip. Codo
SLD/Manager (print) /Ÿo Pass/PR #:
/f0f7
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