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Wisconsin Motor Vehicle Crash Report. Agency Crash Number Date Arrived 08/28/2020. Total Units. School Bus Related. Latitude 43.

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OFFICE USE ONLY

(608) 356-4895

Secondary

Crash

Amended

Crash Type

DT4000 (STANDARD CRASH)

Reportable

Tags School Bus Related

NO

Active School Zone

Government

Property

Reporting

Threshold

Trailer or Towed

Work Zone

Lane Closure

Hit and Run

On Emergency

Total Killed

00

Total Injured

01

Total Units

02

Time Notified

04:58 PM

Date Notified

08/28/2020

Time Arrived

05:18 PM

Date Arrived

08/28/2020

Crash Time

04:58 PM

Crash Date

08/28/2020

Investigating Officer/Deputy

DEPUTY K. MUELLER

Agency Crash Number

20-10563

Primary Crash Document # Document Number Override

6TL0D7W13K

Structure Type Tribal Land

Override

On Roadway Link Offset

1084

On Roadway Link ID#

4557413

Y Coordinate

4809638

X Coordinate

287344.75

Access Control Lat/LongSource

TLT/ILT

Longitude

-89.6264554

Latitude

43.40947098

ON CTHDL EB

1084 FT E

OF BLUFF RD

IN THE TOWN OF MERRIMAC

IN SAUK COUNTY

Location

Special Study Access Control

NO CONTROL

Tribal Land

Crash Classification - Jurisdiction

NO SPECIAL JURISDICTION

Crash Classification - Location

PUBLIC PROPERTY

Relation To Trafficway

TRAFFICWAY - ON ROAD

Animal Type Weather Condition(s)

CLOUDY

Roadway Factor(s)

NONE

Environment Factor(s)

NONE

Road Surface Condition(s)

DRY

Light Condition

DAYLIGHT

Manner of Collision

07 - SIDESWIPE/SAME DIRECTION

First Harmful Event Location

ROADSIDE

First Harmful Event

MOTOR VEH IN TRANSPORT

Crash Scene

Intersection Type

NOT AN INTERSECTION

Junction Location

NON-JUNCTION

Within Interchange Area

NO

Truck Bus or HazMat

NO

Road Grade

DOWNHILL

Road Curvature

STRAIGHT

Surface Type

BLACKTOP (BITUMINOUS)

Traffic Control Inoperative/Missing

NO

Traffic Control

NO CONTROL

Traffic Way

TWO-WAY, NOT DIVIDED

Emergency Motor Vehicle Use

NOT APPLICABLE

Special Function

NO SPECIAL FUNCTION

Most Harmful Event: Collision With

MOTOR VEH IN TRANSPORT

Total Lanes

2

Speed Limit

55

Pre CrashTire

Mark

Direction Of Travel

EASTBOUND

Insurance?

YES

Total HazMat Types

0

Total Trailers

0

Total # Citations Issued

1

Train/Bus # Recorded Total Occs

2

Operating As Endorsements Vehicle Type

(SPORT) UTILITY VEHICLE

Unit Type

AUTOMOBILE

Vehicle Operating As Classification

D CLASS

Unit Status

IN TRANSIT

UNIT

01

01

Unit Summary

Crash Date

08/28/2020

(2)

OFFICE USE ONLY

(608) 356-4895

Drug & Alcoh

Injury

Drug Type

Drug Test Results Drug Test Type

Drug Test Given

TEST NOT GIVEN

Alcohol Test Results Alcohol Test Type

Alcohol Test Given

TEST NOT GIVEN

Suspected Drug Use

NO

Suspected Alcohol Use

NO

INDIVIDUAL

UNIT

Individual Condition

APPEARED NORMAL

Action Other Distracted By Source

UNKNOWN

Distracted By Action

UNKNOWN

Action Prior Action To/FromSchool Location Striking Unit #

01

Time of Death Date of Death Hospital EMS Run # EMS Agency Identifier

MedicalTransport

NOT TRANSPORTED

Trapped/Extricated

NOT TRAPPED

Ejection Path

NOT EJECTED/NOT APPLICA

Ejected

NOT EJECTED

Airbag

NON DEPLOYED

Injury Severity

NO APPARENT INJURY

INDIVIDUAL

UNIT

Tint Compliance Eye Protection Helmet Compliance Helmet Use Seat Position

07 - LEFT

Row

01 - FRONT ROW

Safety Equipment

SHOULDER & LAP BELT

On Duty Accident

01

DL Expire Year

2023

License Status

VALID LICENSE

License Type

NON-CDL DRIVER'S LICENSE

Country of Issuance

UNITED STATES

License Jursidiction

STATE

State

IL

Driver's License Number

Phone Number

(773) 961-5533 EXT.

Weight

110

Height

411

Eyes

BROWN

Hair

BROWN

Race

H

Sex

F

DOB Country of Residence

UNITED STATES

Zip Code

61618

State

IL

City

CHICAGO

PO Box Street Address 2 Street Address

4038 N WHIPPLE ST

Suffix Middle Initial First Name

ALEXIS

Last Name

ACEVEDO

Individual Type

INDIVIDUAL

Use Driver

Address

Citations Issued

1

Role

DRIVER

INDIVIDUAL

01

UNIT

01

Non Motorist

Equipment

Country of Residence

UNITED STATES

Zip Code

60609

State

IL

City

CHICAGO

PO Box Street Address 2 Street Address

3601 S SEELEY AVE

Suffix Middle Initial First Name

CHRISTINA

Last Name

SANCHEZ

Individual Type

INDIVIDUAL

Use Driver

Address

Citations Issued

0

Role

PASSENGER

02

01

Crash Date

08/28/2020

(3)

OFFICE USE ONLY

(608) 356-4895

Drug & Alcoh

Injury

Drug Type

Drug Test Results Drug Test Type

Drug Test Given

TEST NOT GIVEN

Alcohol Test Results Alcohol Test Type

Alcohol Test Given

TEST NOT GIVEN

Suspected Drug Use

NO

Suspected Alcohol Use

NO

INDIVIDUAL

UNIT

Individual Condition

APPEARED NORMAL

Action Other Distracted By Source Distracted By Action Action Prior Action To/FromSchool Location Striking Unit #

02

Time of Death Date of Death Hospital EMS Run # EMS Agency Identifier

MedicalTransport

NOT TRANSPORTED

Trapped/Extricated

NOT TRAPPED

Ejection Path

NOT EJECTED/NOT APPLICA

Ejected

NOT EJECTED

Airbag

NON DEPLOYED

Injury Severity

NO APPARENT INJURY

INDIVIDUAL

UNIT

Tint Compliance Eye Protection Helmet Compliance Helmet Use Seat Position

09 - RIGHT

Row

01 - FRONT ROW

Safety Equipment

SHOULDER & LAP BELT

On Duty Accident

02

DL Expire Year

2024

License Status

VALID LICENSE

License Type

NON-CDL DRIVER'S LICENSE

Country of Issuance

UNITED STATES

License Jursidiction

STATE

State

IL

Driver's License Number

Phone Number Weight

185

Height

503

Eyes

BROWN

Hair

BROWN

Race

H

Sex

F

DOB

INDIVIDUAL

UNIT

Non Motorist

Equipment

Initial Contact Point

11 - LEFT FRONT CORNER

Color

GRY - GRAY

Body Style

UT - SPORT UTILITY VEHICLE

Model

CHEROKEE

Make

JEEP

Year

2017

Vehicle Identification Number

3C4NJDBB7HT680020

Country of Issuance

UNITED STATES

St

IL

Plate Type

AUT - AUTOMOBILE

License Plate Number

BN52943

Crash Date

08/28/2020

(4)

OFFICE USE ONLY

(608) 356-4895

Telephone Number

(773) 961-5533 EXT.

Country of Residence

UNITED STATES

Zip Code

61618

St

IL

City

CHICAGO

PO Box Street Address2 Street Address

4038 N WHIPPLE ST

Date of Birth Suffix Middle First Name

ALEXIS

Last Name

ACEVEDO

Company Name Organization Type

INDIVIDUAL

Use Operator Address

Vehicle Owner Same As Operator

Driver Actions

IMPROPER OVERTAKING / PASSING RIGHT

Bus Use Driver Prior Action Other

What Driver Was Doing

OVERTAKE RIGHT

Vehicle Removed By

OPERATOR

Vehicle Factors

NOT APPLICABLE

Towed Due To Damage

NOT TOWED

Extent Of Damage

FUNCTIONAL DAMAGE

01

01

Vehicle Damage

08 LEFT SIDE REAR, 09 LEFT SIDE MIDDLE, 10 LEFT SIDE FRONT, 11

-LEFT FRONT CORNER

UNIT

VEHICLE

Event

MOTOR VEH IN TRANSPORT

01

Event

02

Event

03

Event

04

Description

UNSAFE PASSING ON RIGHT

Statute Number

346.08

Issue To?

001

UTC Number

BG111156

01

01

Policy Holder Company First Name

ALEXIS

Last Name

ACEVEDO

Organization Type

INDIVIDUAL

Policy Holder Same As Driver

Policy Holder

Same As Owner

Insurance Company

ALLSTATE-VEHICLE-AND-PROPERTY-INS-CO

HOL

01

UNIT

Truck Bus or HazMat

NO

Road Grade

DOWNHILL

Road Curvature

STRAIGHT

Surface Type

BLACKTOP (BITUMINOUS)

Traffic Control Inoperative/Missing

NO

Traffic Control

NO CONTROL

Traffic Way

TWO-WAY, NOT DIVIDED

Emergency Motor Vehicle Use

NOT APPLICABLE

Special Function

NO SPECIAL FUNCTION

Most Harmful Event: Collision With

MOTOR VEH IN TRANSPORT

Total Lanes

2

Speed Limit

55

Pre CrashTire

Mark

Direction Of Travel

EASTBOUND

Insurance?

YES

Total HazMat Types

0

Total Trailers

0

Total # Citations Issued

0

Train/Bus # Recorded Total Occs

4

Operating As Endorsements Vehicle Type

(SPORT) UTILITY VEHICLE

Unit Type

AUTOMOBILE

Vehicle Operating As Classification

D CLASS

Unit Status

IN TRANSIT

UNIT

02

02

Unit Summary

Crash Date

08/28/2020

(5)

OFFICE USE ONLY

(608) 356-4895

Drug & Alcoh

Injury

Drug Type

Drug Test Results Drug Test Type

Drug Test Given

TEST NOT GIVEN

Alcohol Test Results Alcohol Test Type

Alcohol Test Given

TEST NOT GIVEN

Suspected Drug Use

NO

Suspected Alcohol Use

NO

INDIVIDUAL

UNIT

Individual Condition

APPEARED NORMAL

Action Other Distracted By Source

UNKNOWN

Distracted By Action

UNKNOWN

Action Prior Action To/FromSchool Location Striking Unit #

03

Time of Death Date of Death Hospital EMS Run # EMS Agency Identifier

MedicalTransport

NOT TRANSPORTED

Trapped/Extricated

NOT TRAPPED

Ejection Path

NOT EJECTED/NOT APPLICA

Ejected

NOT EJECTED

Airbag

NON DEPLOYED

Injury Severity

NO APPARENT INJURY

INDIVIDUAL

UNIT

Tint Compliance Eye Protection Helmet Compliance Helmet Use Seat Position

07 - LEFT

Row

01 - FRONT ROW

Safety Equipment

SHOULDER & LAP BELT

On Duty Accident

03

DL Expire Year

2021

License Status

VALID LICENSE

License Type

NON-CDL DRIVER'S LICENSE

Country of Issuance

UNITED STATES

License Jursidiction

STATE

State

IL

Driver's License Number

Phone Number

(309) 368-9451 EXT.

Weight

200

Height

602

Eyes

BLUE

Hair

BLOND

Race

W

Sex

M

DOB Country of Residence

UNITED STATES

Zip Code

60156

State

IL

City

LAKE IN THE HILL

PO Box Street Address 2 Street Address

5 LISA CT

Suffix Middle Initial

M

First Name

DUSTIN

Last Name

HARMS

Individual Type

INDIVIDUAL

Use Driver

Address

Citations Issued

0

Role

DRIVER

INDIVIDUAL

03

UNIT

02

Non Motorist

Equipment

Country of Residence

UNITED STATES

Zip Code

60156

State

IL

City

LAKE IN THE HILL

PO Box Street Address 2 Street Address

5 LISA CT

Suffix Middle Initial

M

First Name

SAMANTHA

Last Name

HARMS

Individual Type

INDIVIDUAL

Use Driver

Address

Citations Issued

0

Role

PASSENGER

04

02

Crash Date

08/28/2020

(6)

OFFICE USE ONLY

(608) 356-4895

Drug & Alcoh

Injury

Drug Type

Drug Test Results Drug Test Type

Drug Test Given

TEST NOT GIVEN

Alcohol Test Results Alcohol Test Type

Alcohol Test Given

TEST NOT GIVEN

Suspected Drug Use

NO

Suspected Alcohol Use

NO

INDIVIDUAL

UNIT

Individual Condition

APPEARED NORMAL

Action Other Distracted By Source Distracted By Action Action Prior Action To/FromSchool Location Striking Unit #

04

Time of Death Date of Death Hospital EMS Run # EMS Agency Identifier

MedicalTransport

NOT TRANSPORTED

Trapped/Extricated

NOT TRAPPED

Ejection Path

NOT EJECTED/NOT APPLICA

Ejected

NOT EJECTED

Airbag

NON DEPLOYED

Injury Severity

POSSIBLE INJURY

INDIVIDUAL

UNIT

Tint Compliance Eye Protection Helmet Compliance Helmet Use Seat Position

09 - RIGHT

Row

01 - FRONT ROW

Safety Equipment

SHOULDER & LAP BELT

On Duty Accident

04

DL Expire Year License Status

VALID LICENSE

License Type

NON-CDL DRIVER'S LICENSE

Country of Issuance

UNITED STATES

License Jursidiction

STATE

State

IL

Driver's License Number

Phone Number

(847) 220-0765 EXT.

Weight

140

Height

505

Eyes

GREEN

Hair

BROWN

Race

W

Sex

F

DOB

INDIVIDUAL

UNIT

Non Motorist

Equipment

Country of Residence

UNITED STATES

Zip Code

60156

State

IL

City

LAKE IN THE HILL

PO Box Street Address 2 Street Address

5 LISA CT

Suffix Middle Initial

E

First Name

BRADLEY

Last Name

HARMS

Individual Type

INDIVIDUAL

Use Driver

Address

Citations Issued

0

Role

PASSENGER

05

02

Crash Date

08/28/2020

(7)

OFFICE USE ONLY

(608) 356-4895

Drug & Alcoh

Injury

Drug Type

Drug Test Results Drug Test Type

Drug Test Given

TEST NOT GIVEN

Alcohol Test Results Alcohol Test Type

Alcohol Test Given

TEST NOT GIVEN

Suspected Drug Use

NO

Suspected Alcohol Use

NO

INDIVIDUAL

UNIT

Individual Condition

APPEARED NORMAL

Action Other Distracted By Source Distracted By Action Action Prior Action To/FromSchool Location Striking Unit #

05

Time of Death Date of Death Hospital EMS Run # EMS Agency Identifier

MedicalTransport

NOT TRANSPORTED

Trapped/Extricated

NOT TRAPPED

Ejection Path

NOT EJECTED/NOT APPLICA

Ejected

NOT EJECTED

Airbag

NON DEPLOYED

Injury Severity

NO APPARENT INJURY

INDIVIDUAL

UNIT

Tint Compliance Eye Protection Helmet Compliance Helmet Use Seat Position

07 - LEFT

Row

02 - SECOND ROW

Safety Equipment

CHILD RESTRAINT SYSTEM - FORWARD FACING

On Duty Accident

05

DL Expire Year License Status License Type Country of Issuance License Jursidiction State Driver's License Number

Phone Number

(309) 368-9451 EXT.

Weight Height Eyes Hair Race

W

Sex

M

DOB

INDIVIDUAL

UNIT

Non Motorist

Equipment

Country of Residence

UNITED STATES

Zip Code

60156

State

IL

City

LAKE IN THE HILL

PO Box Street Address 2 Street Address

5 LISA CT

Suffix Middle Initial First Name

ISAAC

Last Name

HARMS

Individual Type

INDIVIDUAL

Use Driver

Address

Citations Issued

0

Role

PASSENGER

06

02

Crash Date

08/28/2020

(8)

OFFICE USE ONLY

(608) 356-4895

Drug & Alcoh

Injury

Drug Type

Drug Test Results Drug Test Type

Drug Test Given

TEST NOT GIVEN

Alcohol Test Results Alcohol Test Type

Alcohol Test Given

TEST NOT GIVEN

Suspected Drug Use

NO

Suspected Alcohol Use

NO

INDIVIDUAL

UNIT

Individual Condition

APPEARED NORMAL

Action Other Distracted By Source Distracted By Action Action Prior Action To/FromSchool Location Striking Unit #

06

Time of Death Date of Death Hospital EMS Run # EMS Agency Identifier

MedicalTransport

NOT TRANSPORTED

Trapped/Extricated

NOT TRAPPED

Ejection Path

NOT EJECTED/NOT APPLICA

Ejected

NOT EJECTED

Airbag

NON DEPLOYED

Injury Severity

NO APPARENT INJURY

INDIVIDUAL

UNIT

Tint Compliance Eye Protection Helmet Compliance Helmet Use Seat Position

09 - RIGHT

Row

02 - SECOND ROW

Safety Equipment

CHILD RESTRAINT SYSTEM - REAR FACING

On Duty Accident

06

DL Expire Year License Status License Type Country of Issuance License Jursidiction State Driver's License Number

Phone Number

(309) 368-9451 EXT.

Weight Height Eyes Hair Race

W

Sex

M

DOB

INDIVIDUAL

UNIT

Non Motorist

Equipment

Initial Contact Point

02 - RIGHT SIDE FRONT

Color

WHI - WHITE

Body Style

UT - SPORT UTILITY VEHICLE

Model

ATLAS

Make

VOLKSWAGEN

Year

2018

Vehicle Identification Number

1V2MR2CA9JC549122

Country of Issuance

UNITED STATES

St

IL

Plate Type

AUT - AUTOMOBILE

License Plate Number

BV73408

Crash Date

08/28/2020

(9)

OFFICE USE ONLY

(608) 356-4895

Telephone Number

(309) 368-9451 EXT.

Country of Residence

UNITED STATES

Zip Code

60156

St

IL

City

LAKE IN THE HILL

PO Box Street Address2 Street Address

5 LISA CT

Date of Birth Suffix Middle

M

First Name

SAMANTHA

Last Name

HARMS

Company Name Organization Type

INDIVIDUAL

Use Operator Address

Vehicle Owner Same As Operator

Driver Actions

NO CONTRIBUTING ACTION

Bus Use Driver Prior Action Other

What Driver Was Doing

RIGHT TURN

Vehicle Removed By

OPERATOR

Vehicle Factors

NOT APPLICABLE

Towed Due To Damage

NOT TOWED

Extent Of Damage

DISABLING DAMAGE

02

02

Vehicle Damage

01 - RIGHT FRONT CORNER, 02 - RIGHT SIDE FRONT, 11 - LEFT FRONT

CORNER, 12 - FRONT

UNIT

VEHICLE

Event

RIGHT TURN

01

Event

MOTOR VEH IN TRANSPORT

02

Event

03

Event

04

Policy Holder Company First Name

SAMANTHA

Last Name

HARMS

Organization Type

INDIVIDUAL

Policy Holder Same As Driver

Policy Holder

Same As Owner

Insurance Company

STATE-FARM-GENERAL-INS-CO

HOL

02

UNIT

Additional Information Photos By Reconstruction By Diagram

Description

Crash Date

08/28/2020

(10)

OFFICE USE ONLY

(608) 356-4895

NONE

Narrative

UNIT 1 ATTEMPTED TO PASS UNIT 2 ON THE RIGHT SIDE AS UNIT 2 WAS TURNING RIGHT IN TO A DRIVEWAY. UNIT 1 STRUCK UNIT 2 AS IT ATTEMPTED TO PASS. THE DRIVE OF UNIT 1 SAID THE VEHICLE HAD STOPPED AND UNIT 2 WAS NOT USING A TURN SIGNAL. THE DRIVER OF UNIT 2 SAID HE USED HIS TURN SIGNAL AND THAT UNIT 1 WAS DRIVING AT A HIGH RATE OF SPEED.

I, a sworn law enforcement officer, agree that I have not added any CJIS data in this report.

Signature

Law Enforcement Agency Zip Code

53913

LEA State

WI

Law Enforcement Agency City

BARABOO

Law Enforcement Agency Street Address2 Law Enforcement Agency Street Address

1300 LANGE COURT

TAS Agency Name

SAUK COUNTY SHERIFF

Law Enforcement Agency Name

SAUK COUNTY SHERIFFS DEPARTMEN

Law Enforcement Agency type

COUNTY SHERIFF

Law Enforcement Agency Jurisdiction

SAUK

Local Agency Number Officer EMail

Officer Badge Number

9120

DNR Officer ID DOT Officer ID

9120

Suffix Officer Middle Name

J

Officer First Name

KYLE

Officer Last Name

MUELLER

Officer Rank

DEP

Agency Space

Law Enforcement Agency

Crash Date

08/28/2020

(11)

OFFICE USE ONLY

(608) 356-4895

TraCS Agency Number

205

BFUNC Agency

5600

ORI Number

WI0570000

Law Enforcement Agency Phone Number

(608) 356-4895 EXT.

Crash Date

08/28/2020

References

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