Crash Information

L O C A T I O N	Date of Accident 8/21/2011	Time of Accident 11:48 AM	County Clarke - 20	Accident occurred within corporate limits of (city)	Law Enforcement Case Number: 2011048808
	Literal Description I35 NB AT 42.8MM				Legal Intervention? No	Private Property? No
					X-Coordinate: 434187.4
					Y-Coordinate 4556979.

U N I T 1	Driver's Name - Last KLIMESH			First PENELOPE			Middle JEAN		Suffix
	City RIDGEWAY			State IA - Iowa, US				Zip 521650000
	Driver's Age 34					Citation Charge Code 1		Citation Charge 1
	Gender Female	State IA - Iowa, US	Class C - Non-commercial vehicle or commercial Veh w/26000 GVWR or less & either 16 Pass Design or Hazmat	Endorsements None	Restrictions None	Citation Charge Code 2		Citation Charge 2
	Alcohol Test Given? 1 - None			Drug Test Given? 1 - None		Citation Charge Code 3		Citation Charge 3
						Citation Charge Code 4		Citation Charge 4
	Seating Position 01 - Front: Left Side / Motorcycle Driver	Injury Status 3 - Non-incapacitating	Occupant Protection 2 - Shoulder and lap belt used		Airbag Deployment 5 - Not deployed	Airbag Switch Status 1 - Switch in ON position		Ejection 1 - Not ejected	Ejection Path	Trapped 1 - Not trapped
	Transported to:					Transported by:
	Insurance Co. Name
	Year 2003		Make Ford - FORD		Model EXCURSION		Style SW		Approximate Cost to Repair or Replace 1500
	Initial Travel Direction 1 - North	Vehicle Action 01 - Movement essentially straight	Speed Limit 70	Point of Initial Impact 07 - Left Side	Most Damaged Area 07 - Left Side	Extent of Damage 2 - Minor damage	Underride/Override 1 - None
	Total Occupants 5	Traffic Controls 01 - No controls present	Vehicle Config. 04 - Sport utility vehicle	Cargo Body Type 01 - Not applicable	Vehicle Defect 04 - Blowout	Driver Condition 1 - Apparently normal	Vision Obscured 01 - Not obscured	Contributing Circumstances, Driver (up to 2)
	SEQUENCE OF EVENTS			First Event 09 - Equipment failure (tires, brakes, etc.)	Second Event 06 - Evasive action (swerve, panic braking, etc.)	Third Event	Fourth Event 33 - Ditch/embankment	Most Harmful Event (by vehicle) 33 - Ditch/embankment
	Emergency Vehicle Type 1 - Not applicable					Emergency Status 3 - Not Applicable
	Carrier Name			City		State			Zip
	Number of Axles			Gross Vehicle Weight Rating		Placard #			Hazardous Materials Released?

ACCIDENT ENVIRONMENT		ROADWAY CHARACTERISTICS Major Contributing Circumstances:	WORKZONE RELATED?	SEQUENCE OF EVENTS
Location of First Harmful Event 1 - On Roadway	Weather Conditions (up to two) 02 - Partly cloudy	Environment 1 - None apparent	Location	First Harmful Event of Crash (use codes 11-42 only) 33 - Ditch/embankment
Manner of Crash/Collision 1 - Non-collision	Weather Conditions (up to two) 02 - Partly cloudy	Roadway 01 - None apparent	Type
Light Conditions 1 - Daylight	Surface Conditions 1	Type of Roadway Junction/Feature 01 - No special feature	Workers Present?

P
E
R
S
O
N

I
N
J
U
R
E
D

Name- Last
KLIMESH

First
MADISON

Middle

Suffix

City

State

Zip Code

Age
4

Sex
Female

Unit No.
1

Seating Position
08 - Rear: Center

Injury Status
4 - Possible

Occupant Protection
5 - Child safety seat used

Airbag Deployment
6 - Not applicable

Airbag Switch Status
3 - No ON/OFF switch present

Ejection
1 - Not ejected

Ejection Path
1 - Not ejected/not applicable

Trapped
1 - Not trapped

Transported to:

Transported by:

NON-MOTORIST

Type

Location

Action

Condition

Safety Equipment

Contributing Circumstances

Unit No. of Vehicle Striking

D
I
A
G
R
A
M

0

NARRATIVE

UNIT 1 WAS TRAVELING NORTHBOUND ON INTERSTATE 35. THE TREAD ON THE DRIVERS SIDE REAR TIRE SEPARATED FROM THE REST OF THE TIRE. UNIT 1 BEGAN TO SLIDE AND UNIT 1 ENTERED THE EAST DITCH AND CAME TO REST. A CHILD IN THE BACK SEAT HAD A MINOR INJURY BUT MEDICAL ASSISTANCE AT THE SCENE WAS DECLINED BY THE PARENTS.

Officer SITZMAN	Badge No. 223	Time Officer Notified of Accident 11:49	Time Officer Arrived At Scene 11:57
Name of Agency P02	Date of Report 8/21/2011	Investigation made at scene? Yes	T.I. #

Any questions about this report may be directed to the following address:
Iowa State Patrol District 02 Office
1619 Truro Pavement
Osceola,IA 50213-8383
Phone: (641) 342-2108
Fax: (641) 342-4653