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HomeMy WebLinkAboutMINUTES - 07161996 - C16 A. CLAIM 80� OF SUcEK�'IS.RS Oc CONTR4 CCSTA COUNTY, CALIFORNIA July 16, 1996 Claim Against the County, Or District governed by) BOAR? ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAI"ANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Superviscrs (Parag-aph IV below), given pursuant to Government Code Amount: $50,000 Section 913 and 915.4. Please note MOD CLAIMANT:Michael J. and Jodi Arakawa JUN 2 8 1996 ATTORNEY: Uq�UNTY COUNSEL Date received MARTINEZ CAUF. ADDRESS: 4360 Clayton Rd. , Apt. 3 BY DELIVERY TO CLERK ON Concord, CA 94521 BY MAIL POSTMARKED: via: Risk Mgmt. I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: June 27, 1996 IqiL DeputyLOR, Clem II. FROM: County Counsel TO: Clerk of the Board of Supervisors ! This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: /�/ BY: Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOAR; ORDER: By unanimous vote of the Supervisors present (V ) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated /�/a 9 1,_PHIL BATCHELOR, Clerk, By . Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this chatter. If you want to consult an attorney, you should do so immediately. *For additional warnin0 see reverse side Of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that 1 am now, and at all times herein mentioned, have been a citizen of the United States, over age 16; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: _ BY: PHIL BATCHELOR b Deputy Clerk —4 6 tj CC: Ccu^•:y Counsel County Administrator Claimant called sa ing he never recieved a copy of the board order rejecting his claim on July 16, 1996. ,,Mailed out a copy on January 13, 1997. Or i mb RECEI ED Michael J. and Jodi Arakawa 4860 Clayton Road, Apt. 3 JUN 2 7 19% Concord, CA 94521 Wk- Telephone: (510) 798-3457 CLERK��ACOSTACO. RS CLAIM FOR DAMAGES AGAINST MERRITHEW MEMORIAL HOSPITAL To: Merrithew Memorial Hospital 2500 Alhambra Avenue Martinez, CA 94553 MICHAEL AND JODI ARAKAWA hereby present their claim for damages. The particulars are as follows: A. CLAIMANTS' Michael J. and Jodi Arakawa 4860 Clayton Road, Apt. 3 Concord, CA 94521 B. ADDRESS TO WHICH NOTICES ARE TO BE SENT Michael J. and Jodi Arakawa 4860 Clayton Road, Apt. 3 Concord, CA 94521 C. DATE OF OCCURRENCE January 3 through January 6, 1996. Claimants' infant died on January 5, 1996. D. PLACE OF OCCURRENCE Merrithew Memorial Hospital 2500 Alhambra Avenue Martinez, CA 94553 E. OTHER CIRCUMSTANCES OF OCCURRENCE The Claimants' decedent died at Merrithew Memorial Hospital on January 6, 1996. Claimant Jodi Arakawa presented at Merrithew Memorial Hospital for delivery of the Arakawas' child by hospital personnel and physicians. The labor and delivery were improperly instituted, managed and monitored causing complications, including but not limited to shoulder dystocia and cranial hemorrhage. As a result, claimants ' infant was born in grave condition and died on January 6, 1996. The care and treatment rendered to claimant Jodi Arakawa and the decedent before, during and after labor and delivery was a breach of the applicable standards of medical and nursing care. In addition, claimants allege that Merrithew Memorial Hospital inadequately evaluated the credentials and 1 • I capabilities of the physicians and staff who participated in the pre-natal, natal and delivery care, and inappropriately gave that staff hospital privileges, legally causing the decedents ' death. F. ITEMIZATION OF INJURIES AND DAMAGES TO THE CLAIMANTS The decedent died on January 6, 1996, as a direct result of the negligent medical care. The claimants are the decedents' parents. The claimants have incurred damages for funeral and burial expenses, lost economic support, and general damages stemming from the decedent's death. Claimants, who witnessed the injurious pre-birth care and delivery leading to his demise, also seek recovery under Dillon v. Legg. Claimant Arakawa also seeks damages for personal injury sustained before, during and after the delivery as a result of negligent care she received. Jodi Arawaka reserves the right to recover all damages allowable by law including medical expenses, lost income, lost earning capacity and general damages. G. EMPLOYEES CAUSING INJURY AND DAMAGE At this time claimants identify Anna Hejinian, M.D. , Charles J. Berletti, M.D. , Dr. Miramonte who were present, provided care and may be responsible. The names of additional employees of said public entity responsible for the occurrence herein, are unknown to claimants at this time. H. AMOUNTS CLAIMED Damages for the claimants exceed $50, 000 and the appropriate court of jurisdiction is the Superior Court of Contra Costa County. DATED: June 18, 1996 ICHA J. ARAKAWA DATED: June 18, 1996 _ JODI ARAKAWA WP51\ARAKAWA\CLAIM.DMG The Board of SupervisorsContra Cl�'' a' etk of the Board • County Administration Building and Costa Co„aty Adminiarator 651 Pine Street, Room 106 Martinez,California 94553-1293 County (5 to)335-1900 Jim Ropers, 1 at District Gayle B.Uilkema, 2nd District E-• E o Donna Gerber, 3rd District Mark DeSsulnier, 4th District Joe Canclamilla, 6th District A coi.r January 16, 1997 Michael J. and Jodi Arakawa 1680 Donaldson Court Concord, CA 94521 By this letter I am confirming my telephone conversation with you this day regarding the status of your claim. Following further review with our legal counsel, I am sending you a certified copy of the Original Board Order on file with this office, based on your statement that you had never received it. The date on the attached affidavit of mailing starts your time statute. Jeanne Maglio, Chief Clerk By: Shirley Casillas, Deputy Clerk r cc: Andrea Cassidy, Deputy County Counsel sc/attachments BOARD OF SUPERVISORS , CONTRA COSTA COUNTY , CALIFORNIA AFFIDAVIT OF MAILING In the Matter of ) Claim of Michael J. & Jodi Arakawa I declare under penalty of perjury that I am now, and at all times herein mentioned have been, a citizen of the United States , over age 18; and that today I deposited in the United States Postal Service in Martinez , California , postage fully prepaid , a certified copy Of claim from July 16, 1996, Item # C.16. to the following : Michael J. and Jodi Arakawa 1680 Donaldson Court Concord, CA 94521 I declare under penalty of perjury that the foregoing is true and correct. Dated January 16, 1997 at Martinez, California. Deputy er CLAM BOA;O GS c '.! Ec c �IcC:c G� CONTRA C^STA COUNTY, Ck!7ORNIA � July 16, 1996 Claim Against the County, Or District governed by) BOA O ACTION the Board of Supervisors, Routing Endorsements, ) NG?ICE TO CLAIMANT and Board Action. .All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $789,000 Section 913 and 915.4. Please note aI� ZV 110 CLAIMANT: Lucille Brock j� �J JUN 2 4 1996 ATTORNEY: John B Hallbauer, Esq. COUNTY COUNSEL The Peri Executive Centre Date received MARTINEZ CALIF. ADDRESS: 2033 N. Main St. , Ste.700 BY DELIVERY TO CLERK ON June 24, 1996 Walnut Creek, CA 94596 BY MAIL POSTMARKED: June 18, 1996 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. gg DATED: June 24, 1996 �q11 De�uLyLOR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ;i1 This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: r�/�� 2-11� BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: UPHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. if you want to consult an attorney, you should do so immediately. *For additional warnino see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator JOHN B. HALLBAUER . Attorney at Law A Professional Corporation REC ED JUN 1 91996 June 18, 1996 RMAOARD OFSUPFRv150RSONTRA COSTA CO. �t Clerk Board of Supervisors County Administration Bulding Room 106 Martinez, California 94553 Re: Claim by Lucille Brock Dear Sir/Madam: Enclosed pleae find Claim by Lucille Brock. We have enclosed a copy. Please stamp the copy "Received" and return to us in the self-addressed stamped envelope provided. Thank you. Very truly yours, LAW OFFICES OF JOHN B. HALLBAUER A Professional Corporation Charlotte Bailey, Secretary Enclosure The Peri Executive Centre 2033 North Main Street,Suite 700 Walnut Creek,CA 94596-3728 Tel. (510)932-8500 Fax(510)932-1961 Claim to: BOARD Of SUPERPiMES, OF oONM =A ooQrrrSr � . !o zNsrRIICTIONS 710 CEAMW A: Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue an or before December 319 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of actions for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of 'action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code 5911.2. B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. 0 0 # # * # # 0 * * * 0 # # # # * 0 # # 0 0 a 0 0 # # a 0 0 # 0 0 # # 0 * 0 # # * # # RE: Claim By ) Reserved for Clerk's filing stamp LUCILLE BROCR ) RECEIVED $x:. ) � e Inst the County of Contra Costa ) jJM 4 (996 or ) CLERK F SUP RYISORS District) CONTRA COSTA CO. Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 789,000 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) December 23, 1995 at 1740 2. Where did the damage or injury occur? (Include city and county) Railroad Avenue, 13 feet west of First Street, Rodeo, Contra Costa County, CA - ------ -- — 3. How did the dam 8e or inJurY occur? (Give !till details; use extra paper if required) This pedestrian/pickup truck collision occurred as Jimmy Brock was walking from the north curb of Railroad Avenue towards the south curb of Railroad Avenue. Ronald Smith was traveling on First Street and made a left turn onto westbound Railroad Avenue at approximately 20 mph toward Jimmy Brock.As Jimmy Brock (decedent)was crossing the street,Ronald Smith's pickup truck struck Jimmy Brock. 4. What particular act or emissions on the part of county or district officers, servants or employees caused the injury or damage? . The intersection was dangerous and unsafe and a cause of the pedestrian/pickup accident. The County failed to maintain the intersection in a safe manner: poor lighting,no tree maintenance,an uncontrolled intersection,and no signage warning drivers of the hazards. (over) • Lac "4J6" y+ 4 ' .County Road Maintenance and Traffic Operations e" I , ' to 6. What damage or injuries do you claim resulted? (Give 21:11 extent of injuries or damages claimed. Attach two estimates for auto damage. Wrongful death -special damages: $339.500 loss of society and comfort: 450,000 $789,000 7. How was the amount claimed above =Mputed? (Include the estimated amount of any prospective injury or damage.) Hospital and medical expenses: John Muir: $ 75,000 Helicopter: 6,300 Funeral expenses: 8.200 $250,000 8. Names and addresses of witnesses. doctors and hospitals. • See attached_CHP report for witnesses • John Muir Hospital Dr. Baker Dr. Car Dr.Roberts 9. List the expenditures you made on account of this accident or injury: WE Im AM= SEE RESPONSE TO NUMBER 6 ABOVE Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SW NOTICES T0: (Attorney) or bv some person on his behalf." Name and Address of Attorney JOHN B. HALLBAUER, ESQ. Claimant'sgnature LAW OFFICES OF JOHN B. HALLBAUER The Peri Executive Centre 710 First Street, #A 2033 N. Main Street, Suite 700 Address Walnut Creek, CA 94596 Rodeo, California 94572 Telephone No. (510) 932-8500 1 Telephone No. (510) 799-2686 ! ! ! a ! ! erT a a • ! a ! ! a f ! N0TIC-E Section T2 of the Penal Code provides: . *Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and tine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. IrCoLusla" VotaaA4QDWSION REPORTOPI 0429?83763 PAGE ofa" r �® C" LOCALR[►ORTMW.iII iL NpW SER Nii RW REIORTSA7 oRiTISR .EAT r � Ocamum rO. BAY TEAR TIME(]W[) NCJC S OFRC[R L 0. , _ iG�o E /Z =2319-5 APY4 9_.326 J2Y29 ' SiFORrATKMI DAroFwE[K TOW AWAY PHOTOGRAPHSw: u /N oP SMTWTFS Ores omo 0 STATE HWV REL OAT SRSRSECTTIDM WRM J OA: 13 PEETI M A-4 A l/ / O 0- 1 IZNONE PARTY pRIYERiLJC@ISE MIRISER fTw7E CLAM SAFETY YWl MARE/YODEL/COLOR LICENSENWDEN ETI Z, ILAJ• . . . DIVER (1%Mr.DBMS,LAST) 0 ' _J/�7l%yl y I/�1�10� 2nC/C pomm. STREET AODF"o - owN[RT+A Nu OSAM AS DRIVER lam to _71D PARI® ertr r irwTE olR+[1rE ADDRESS E AE owvER 11 0vHlCLlI am- in MHGMT wt1OMT- MRR�.wTs RAC[ orPOYflON OF VEMICL[o11 ORDip Or. ODRN[R ❑OTHER o - 16-DI b6l z , /S77 OTME# Mort►IIDIt-;;',"=^ !x-. SYONesS PHONE. PRIOR MECHANICAL DOMCiIf: $110MAPPAIIIJIM111 REFER TO NARRATIVE C .bT: ^'4 , ._.. ( .. , _ CHIP uEE ONLY .. D[1CIESt V WCL[DAMAGE -... 711 WDAMAGED AREAVSHIC t PONCYMWSERSPEID PCFDDT D CA D ' lee a, Puc DI LOW _.. x PARTYDRIVEIITi LICBRMRNER STATE CLASS SAFETY VEL YEAR MAKE/rODEL/COL011 NIANIER STA-. .�:. ,�.--•-- ..,. .__ _.. 2-2 - P ofavm ( .LAST) - :. .. Psom Fnuu„� es „ E OVAM"MATE �UMIS AS DREYER ❑ �-u-�YYIP1_�EL L �vE - PARKEaI.AA OWNER'S ADDR[M ®SAME AS DRR/[II vMa0l'SICLELSS EIcY- SEE= MAEI EYES NDwr wEKRR MIRMDATE RACE DIS►OINTIOMOFVEMK:LEONO110ERSOF: C[R ®DISvER OTHER 0 _ 5/D /loft %/o . 7 ' yZ"Sow musomm PHONE ❑ (��lo w- so- slo/ ��D� 797 ,�529--' FISOII rECNANCAL oEFErn: MONS AF►ARSNr� R[F[II TO W1111Anv[ Cw USEVEHICLEONLY 0[ECIIIK VEHICLE OAYAO[ SHAD[IN DAMAGED AREA SA Pair MASS" TY.E OYO OE1LLWOII OTTOTAL JOH;:E�ORMIG"WAY ;►EEO PCF DOT D CAD ICC D PLIC q ' 106,00 2362COu.r. I C .111 PARTY yC@/SE NLMSER STATE CLASS SAFETY YEAR MIKE/YODEL/COLOR LICENSE MAIDEN STAT 3 EOYM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DRIVER NAME(R DOLE.LAST) • . ►FOES TRE[TADOIIEM OWNLRTi NAME OEAME AS DRIVER MAN PARKED CRY I STATE I L► OWNERS ADDRESS O E AS DRIVER VOWLS SICl- SEZ I HAIR ErtS I MEIGNT I wEl MO. SIRTMOATE RACE DISPOSITION OF VEHICLE ON ORDERS Or ❑ CEA ODRIVER `[-]OTHER . COST . DAY . TEAM i OTHER HOME PHONE SUSINESS P PRM MECHANICAL DEFECTS: NONE APPARENTol REFE11 TO N ---❑ cH.USE ONLY oEEewu VENICE[oAYAO[ E N DAMAGED MEA INSURANCE CARRIER ►OLICY NWS VINCLETYP[ O I LSIK. ONONE OLSNOR i ❑TDD. DMUGR OTOTAL ' DIR.OP IOMSTIPISITORMIC"WAY SPEED JPCI DOT O CA O ICC D ►UC D TRAVEL LIMIT PREPAR T NAME DISPATCH NOTIFIED REVIEWER'S NAME GATE REVIEWED /LL J 12—?2 O [ YES ❑ NO � N/A • r2dwdz �� TRAFFIC COLLISIONCODING-- E 2 OF" F `eAv Y[Alt .l �`t r"ICIIALI.12 �2,p• Nweu R DOCI..1gNOiDAYAOOWNE"NAMI AD0MM , /� /� ❑NOT O- [ //1I/ /•V/ SEATING POSITION SAFETY EQUIPMENT EJECTED FgOM VEHICLE OCCUPANTS L-AM ABAG DEPLOYED Y/C BICYCLE-NEWET _ -NONE IN VEHICLE Y-AIR BAG NOT DEPLOYED e-NOT EJECTED B•UNKNOWN N-OTHER DRIVER 1•FULLY EJECTED C-LAP BELT USED ►.NOT REQUIRED V. 2-PARTIALLY EJECTED D-LAP BELT NOT USED W-YES 3-UNKNOWN fl 2 3 2-ORIVER TO PASSENGERS E-SHOULDER HARNESS USED PASSENGER 4 S G 7•STATION WAGON REAS F-SHOULDER HARNESS NOT USED �� X-NO -REAR OCTRK.OR VAN G-LAP/SHOULDER HARNESS USED O-IN VEHICLE USED C. Y.YES f•POSITION UNKNOWN H-LAP/SHOULDER HARNESS NOT USED R-IN VEHKxE NOT USED -OTHER -PASSIVE RESTRAINT USED i-BM VEHICLE USE UNKNOWN 7 K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE U-NONE IN VEHICLE ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK V)SHOULD BE EXPLAINED IN THE NARRATIVE. PRIMARY COLLISION FACTOR TRAFFIC CONTROL 2 3 TYPE OF VFJICLE 2 3 MOVEMENT PRECEDING LIST NUMBER(f)OF PARTY AT FAULT -COLLISION * A VAC SECTION VIOLATED: aT CONTROLS FUNCTIONING APASSENGER CAR/STATION WAGON ASTOPPED 152 -C• No CONTROLS NOT FUNCTIONING• BPASSENGER CAR W/TRAILER B PROCEEDING STRAIGHT + OTHER IMPROPER DRIVING•: CONTROLS OBSCURED MOTORCYCLE/SCOOTER RAN OFF ROAD - D NO CONTROLS PRESENT/FACTOR• D PICKUP OR PANEL TRUCK D MAKING RIGHT TURN OTHER THAN DRIVEHL' TYPE OF COLLISION E RCKUP/PANEL TRUCK W/TRAILER MAKING LEFT TURN tMCNOYYN• HEAD-ON TRUCK OR TRUCK TRACTOR MAKING U TURN • SIDESWIPE TRUCK/TRUCK TRACTOR W/TRLR. BACKING REAR END SCHOOL BUS SLOWING/STOPPING WEA ( MARK I TO 21TEMS) BROADSIDE OTHER BUS 1 PASSING OTHER VEHICLE CLEAR HIT OBJECT EMERGENCY VEHICLE J CHANGING LANES CLOUDY OVERTURNED I(HIGHWAY CONST.EQUIPMENT PARKING MANEUVER RAINING VEHICLE/PEDESTRIAN BICYCLE ENTERING TRAFFIC SNOWING OTTER•: OTTER VEHICLE OTHER UNSAFE TURNING FOC/VISIBILITY FT. MOTOR VEHICLE INVOLVED WITH PEDESTRIAN RING INTO OPPOSING LANE OILER•: ANON-COLLISION MOPED PARKED W� PEDESTRIAN �'ro LIGHTING OTHER MOTOR VEHICLE TRAVELING WRONG WAY JA DAYLIGHT MOTOR VEHICLE ON OTHER ROADWAY ' 2 3 OTHER ASSOCIATED FACTORS) OTHER•: DUSK-DAWN PARKED MOTOR VEHICLE (MARK 1 TO 21TEM8) vc vaun": DARK-STREETLIGHTS TRAIN A �Ys DARK-NO STREET LIGHTS BICYCLE No DARK.STREET LIGHTS NOT ANIMAL: B ve s[cIION vaullDN: ortco FUNCTIONING• Ova ROADWAY SURFACE SOBRIETY-DRUG FIXED OBJECT: vcp 1 2 3 PHYSICAL A DRY I OYs (MARK 1 TO I ITEMS) YVETOTHER OBJECT: �Np HAD HOT BEEN DRINKING SHOWY-ICY D SLIPPERY(MUDDY.OILY.ETC.) E VISION OBSCUREMENT: B HBO-UNDER INFLUENCE NBC.NOT UNDER INFLUENCE•j INATTENTION•' I ID HBD-IMPAIRMENT UNKNOWN-1 ROADWAY CONOITION(S) F PEDESTRIANS INVOLVED G STOP i GO TRAFFIC E UNDER DRUG INFLUENCE (MARK 1 TO 2ITEMS) H ENTERING/LEAVING RAMP ANO PEDESTRIAN INVOLVED 1 PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL EHNO DEEP RUT• CROSSING IN CROSSWALK PREVIOUS C WITH ROAD IMPAIRMENT NOT KNOWN MATERIAL ON ROADWAY• ATINTERSECTION I(DEFECTIYE YEHL EQUIP.: �Ep NOT APPLICABLE CTION ON ROADWAY• CROSSING IN CROSSWALK-NOT �p I SLEEPY/FATIGUED UCTION-REPAIR ZONE AT INTERSECTION 0� SPECIAL INFORMATION D ROADWAY WIDTH CROSSING-NOT IN CROSSWALK (-UNINVOLVED VEHICLE AHAZARDOUS MATERIAL Jr • IN ROAD-INCLUDES SHOULDER OTHER•: .: NOT INROAD NONE APPARENT UAL CONDITIONS APPROACHING/LEAVING SCHOOL BUS RUNAWAY VEHICLE SKETCH MISCELLANEOUS :;rte Lvs A/ wieAls NORIN ' VZ E/8 "AE c D.r_c 9 1 U. »l t ADI ell RATE Of,BAUfORNA INJURED / WITNESSES / PASSENGERS • DATE Of COLUSIOy//2 •J�,�s TIME(Z- IyD -C NUMBER /32V OFRCER 1../^1W2 NUMBER ' �B, V4 I - EXTENT OF INJURY ( "X" ONE) INJURED WAS( "X" ONE WITNESS ►ASSENGER AGE 8EE PARTY SEAT SAFETY EJECTN ONLY ONLY fSEVERE OTHER VISIBLE COMPLAINT NUMBER POS. 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