ROAD ON WHICH CRASH OCCURRED

INTERSECTING ROAD, OR IF CRASH NOT AT INTERSECTION, NEAREST INTERSECTING ROAD OR REFERENCE MARKER
County
Crash Date Crash Time
City
Name
Case
(MM/DD/YYYY) (24HRMM) ID
Local
Use
Name
Outside
City Limit
In your opinion, did this crash result in at least
$1,000 damage to any one person's property?
X Yes
No
Latitude
(decimal degrees)
Latitude
(decimal degrees)
1 Rdwy.
Sys.
Hwy.
Num.
2 Rdwy.
Part
Block
Num.
3 Street
Prefix
Street
Name
4 Street
Suffix
X X
X
X
Crash Occurred on a Private Drive or
Road/Private Property/Parking Lot Toll Lane
Toll Road/ Const.
Zone
Workers
Present
Street
Desc.
Speed
Limit
Yes
No
Yes
No
Yes
No
Sys.
1 Rdwy.
Num.
Hwy.
Part
2 Rdwy.
Num.
Block
Prefix
3 Street
Name
Street
Suffix
4 Street
Int.
At
Distance from Int.
or Ref. Marker
FT
MI
or Ref. Maker
3 Dir. from Int.
Marker
Reference
Desc.
Street
Num.
RRX
0 7 2 5 2 0 1 4 0 3 0 9
Odessa
IH 20 1
900
W I 20
75
LR 1 S
Grandview
AVE
.5 W
Ector
14-0018184
X Yes
No
X Yes
No
Expired
Exempt
X Owner
Lessee
Unit Hit and
Run
LP
State
LP
Num.
VIN
Num.
5 Unit Parked
Desc. Vehicle
Veh.
Year
6 Veh.
Color
Veh.
Make
Veh.
Model
7 Body
Style
Pol., Fire, EMS on
Emergency (Explain In
Narrative if checked)
(MM/DD/YYYY)
DOB 8 DL/ID
Type
DL/ID
State
DL/ID
Num.
9 DL
Class
10 CDL
End.
11 DL
Rest.
Address (Street,
City, State, ZIP)
Not Applicable - Alcohol and
Drug Results are only reported
for Driver/Primary Person for
each Unit.
Owner/Lessee
Name & Address
Proof of
Fin. Resp.
26 Fin.
Resp. Type
Fin. Resp.
Name
Fin. Resp.
Num
Fin. Resp.
Phone Num.
27 Vehicle
Damage Rating 1
27 Vehicle
Damage Rating 2
Towed
By
Towed
To
Vehicle.
Inventoried
1 1 TX 1E75564
1 M 1 A J 0 6 4 5 7 N 0 1 1 9 2 8
2 0 0 7 WHI TR
2 TX 11945132 A
N H A
7 8 1 0 2 9 0 1
11252 Center Pt, San Antonio, TX
Name: Last, First, Middle
Enter Driver or Primary Person for this Unit on first line
Helfrich, Kevin 1 1 1 B 41 W 1 1 1 1 97 N 96 96 97 97
2 Bryan Insurance Agency KPP1019222
(940) 549-2525
LLC, Rio, Red Services, 4309 S Crk 1131, Midland, TX, 79706
Neal Pool 1117 S. Grant
MACK TR
9 L T 5
Yes
X No
X Yes
No
Expired
Exempt
X Owner
Lessee
Unit Hit and
Run
LP
State
LP
Num.
VIN
Num.
5 Unit Parked
Desc. Vehicle
Veh.
Year
6 Veh.
Color
Veh.
Make
Veh.
Model
7 Body
Style
Pol., Fire, EMS on
Emergency (Explain In
Narrative if checked)
(MM/DD/YYYY)
DOB 8 DL/ID
Type
DL/ID
State
DL/ID
Num.
9 DL
Class
10 CDL
End.
11 DL
Rest.
Address (Street,
City, State, ZIP)
Not Applicable - Alcohol and
Drug Results are only reported
for Driver/Primary Person for
each Unit.
Owner/Lessee
Name & Address
Proof of
Fin. Resp.
26 Fin.
Resp. Type
Fin. Resp.
Name
Fin. Resp.
Num
Fin. Resp.
Phone Num.
27 Vehicle
Damage Rating 1
27 Vehicle
Damage Rating 2
Towed
By
Towed
To
Vehicle.
Inventoried
2 6 TX 052C393
1 T 9 T S 4 0 2 9 E R 7 1 9 3 2 4
2 0 1 4 BLK TL
Name: Last, First, Middle
Enter Driver or Primary Person for this Unit on first line
2 Bryan Insurance Agency KPP1019222
(940) 549-2525
Red, Rio, 4309 S. Crk 1131, Midland, TX, 79706
Neal Pool 1117 S. Grant
trox trailer
9 L T 5
= These fields are required on all additional sheets submitted for this crash (ex.: additional vehicles, occupants, injured, etc.).
X
Num.
Total
Units
Total
Num.
Prsns.
TxDOT
Crash ID 2 1
SCHOOL BUS RAILROAD CMV FATAL MAB SUPPLEMENT
ACTIVE
SCHOOL ZONE
Law Enforcement and TxDOT Use ONLY
Texas Peace Officer's Crash Report (Form CR-3 1/1/2010)
Mail to: Texas Department of Transportation, Crash Records, P.O. Box 149349, Austin, TX 78714. Questions? Call (512) 486-5780
Refer to Attached Code Sheet for Numbered Fields
Page of
1 3
Num.
Unit Prsn.
Taken By
Date of Death
Taken To
(24HRMM (MM/DD/YYYY) Num.
Time of Death
Unit
Num.
Prsn.
Num.
Charge Citation/Reference Num.
Damaged Property Other Than Vehicles Owner's Name Owner's Address
X
X
RGVW
GVWR
X Yes
No
X
Yes
No
Unit
Num.
10,001+ LBS.
TRANSPORTING
9+ CAPACITY
28 Veh. 29 Carrier
ID Type
Carrier
ID Num.
HAZARDOUS MATERIAL
Oper.
Carrier's
Corp. Name
Carrier's
Primary Addr.
30 Rdwy.
Access
31 Veh.
Type
32 HazMat
Class Num.
HazMat
ID Num
32 HazMat
Class Num
HazMat
Released
HazMat
ID Num.
33 Cargo
Body Style
Trailer 1
Unit
Num.
X
RGVW
GVWR
34 Trlr.
Type
Trailer 2
Unit
Num.
34 Trlr.
Type
RGVW
GVWR
Sequence
Of Events
35 Seq. 1 35 Seq. 2 35 Seq. 3 35 Seq. 4
Total
Num. Axles
Total
Num. Tires
Enviromental and Roadway Conditions 36 Contributing Factors (Investigator's Opinion) 37 Vehicle Defects (Investigator's Opinion)
Unit Num. Contributing May Have Contrib. May Have Contrib. Contributing 38
Weather
Cond.
39
Light
Cond.
40
Entering
Roads
41
Roadway
Type
42
Roadway
Alignment
43
Surface
Condition
44
Traffic
Control
(Attach Additional Sheets if Necesary)
Investigator's Narrative Opinion of What Happened
Field Diagram - Not to Scale
Indicate
North
Time Notified
(24HRMM)
How
Notified
Time Arrived
(24HR:MM)
Report Date
(MM/DD/YYYY)
Invest.
Comp.
Investigator
Name (Printed)
ID
Num.
District/
Area
Agency
ORI
Num.
1 Rescue 1 1 MCH
Center Barrier Cable Texas, The, State Of
1 1 1 02437715
4309 S. Crk 1131, Midland, TX, 79706 Rio Red Services
1 1
4 18
3
3 9 9 1 A N
97 2 1
7 4 3 8
1 2 97 4 4 1 96
1 22 40
T X 0 6 8 0 2 0 0
ODESSA POLICE
0 3 0 9 0 3 1 4
dispatched
0 7 2 5 2 0 1 4
Cory V Wester 7579
A larger diagram is located on page 3
Unit #1 was towing Unit #2 traveling westbound in the inside lane of the 900
block of W. I20. Unit #1 failed to control speed and left the roadway. Unit #1
struck the barrier cables in the median of the interstate and rolled from left to
right causing L&T damage to both Unit #1 and Unit #2. The driver of Unit #1
was transported to MCH with non-life threatening injuries. The estimate of the
damage to the barrier cables can not be made at this time.
Page of
2 3
Case ID TxDOT Crash ID
Law Enforcement and TxDOT Use Only
Form CR-3 1/1/2010
14-0018184
1 9 9 0 0
Field Diagram - Not to Scale
Indicate
North
Page of
3 3
Case ID Agency
CR-3 Diagram
14-0018184 ODESSA POLICE