MOTOR VEHICLE ACCIDENT REPORT

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP59-00882R000300330072-1
• Release Decision: RIPPUB
• Original Classification: K
• Document Page Count: 4
• Document Creation Date: December 9, 2016
• Document Release Date: December 26, 2000
• Sequence Number: 72
• Publication Date: March 22, 1955
• Content Type: FORM

,S,p.pppygd For Refease 2001/03/01 : CIA-RDP59-0ft82R000300 30072
Date
UNITED STATES
DEPARTMENT OF THE INTERIOR
NATIONAL PARK SERVICE
NATIONAL. CAPITAL PARKS
MOTOR-VEHICLE ACCIDENT REPORT
U. S. PARK POLICE
USE TYPEWRITER OR WRITE PLAINLY IN INK
LOCATION OF ACCIDENT
TIME OCCURRED
On
St
t 19
D
.
/
a
Day of
At or between St.
the
week
And_
St
---
.
In pity or town of /
A. M.
Time QiP'
On Highway No. miles of
CN.S.E.W.)
And feet of
(N. S. E. W.) (Road (give number), bridge, railroad crossing, numbered pole, filling station, eta.)
Or at intersection with Highway No. (Be as accurate and explicit as possible.)
VE ICLES INVOLVED IN ACCIDENT
Mak
Type
Year /f
built
//,!9 411 C,
Lie. Note/ State
p
Owner
3
Z
Drive
GC o (CityortownFOIAb6
,tea
M
Driving
A8e zT
x Race experience O
Operator's ' Li
Cha
ff
J
(City or town)
c. No. `5413 / y / State 3
,
y
u
eur s
W
1
Direction Point of impact
~
SStimated`damage;'~ ?ZU 00
r
(N. S. E. W.) ~C
!?
(Right front,ieft side, etc.)
J
Date car was last inspected -' J 19 Was car insured?
Estimated speed Estimated speed at ~Lawful
'
t
(Yes or no) Y -~
Maxi um safe speed -
before ac
den
moment impact
Sp vl
under conditions 0 /4~#
Make
TYPe
Year
built
Lie. No
?~ "/- -tCA State S
~~pp
(Sedan, trucks to.)
.
e
Owner
Z
I IF
Driver
25X1A9a
(street rasa (City or town)
Driving Operator's i Lie. No. State '~ ,-'
Ag ex Rape
i
'
- exper
ene
yr. Ch eur
sf
Direction. Point of impact
(N. S. E. W.
1/
~)
igbt front, left side, etc.)
Estimated damage, $ . (l,00
.5
~
Date car was last eeted , 19- Was car insured?
Estimated speed Estimated speed at Lawful
before acciden
~//
t
f i
t
(Yes or no)
Maximum safe speed
"Z M~
momen
.
o
mpac
speed
under conditions ?
Make: Type
Year
built
Lie. No. State
(Sedan, truck, taxi, eta)
Owner
(Name) (Street address)
Driver
(City or town)
PQ
(Name) (Street address) (City or town)
Driving Operator's ll Lie
No
St
t
A
Fq
ge Sex Race experience
yr. Chauffeur's)
.
.
a
e
Direction Point of impact
(N. s. E. W.)
(Right front, left side, etc.)
Estimated damage, $
Date car was last inspected , 19
Estimated speed Estimated speed at
~ Was car insured?
Lawful
(Yes or no)
Maximum safe speed
before accident, moment of impact
speed
under conditions
EsA aF?hrekes~9iIQ9~h0oz>kBDP59-00
882R0003003300472-1
 ApplOVEM r-01 F-MME15 1.
a A"
NAME AND ADDRESS
AGE
SEA
RACE
CHECK
DESCRIPTION OF INJURIES
Name
^ Injured.
^ Killed.
^ Cuts. ^ Bruises. ^ Broken bones.
^ Internal injuries. ^ Shook.
Address
^ Pedestrian.
Pass. in car
Describe
Name
^ Injured.
^ Killed.
^ Cuts. ^ Bruises. ^ Broken bones.
^ Internal injuries. ^ Shock.
Address __
^ Pedestrian.
Pass. in car
Describe
Name
^ Injured.
^ Killed.
^ Cuts. ^ Bruises. ^ Broken bones.
^ Internal injuries. ^ Shock.
Address ___
^ Pedestrian.
Pass. in car
Describe
Name --_
^ Injured.
^ Killed.
^ Cuts. ^ Bruises. ^ Broken bones.
^ Internal injuries. ^ Shock.
Address __.__.
^ Pedestrian.
Pass. in car
Describe
Name- _
^ Injured.
^ Killed.
^ Cuts. ^ Bruises. ^ Broken bones.
^ Internal injuries. ^ Shock.
Address
^ Pedestrian.
Pass. in car
Describe
Name -_~-
^ Injured.
^ Killed.
^ Cute LI Bruises. ^ Broken bones.
^ Internal injuries. ^ Shock.
Address
^ Pedestrian.
Pass. in car
Describe
Injured were taken to By
I Are cars in running condition? Stored at
M
r Vehicle With-
1. Other motor vehicle.
2. Pedestrian.
3. Railroad train.
4. Street car.
5. Bicycle.
6. Horse-drawn vehicle.
7. Other vehicle.
8. Animal.
9. Fixed Gbry~ eet
10. ll'fl4ibli.'d For Release 2001/03/01
IlL~'
LIGHT CONDITIONS
1. Daylight.
2. Dusk-Semidarkness.
3. Darkness-Street lights.
4. Darkness-No street lights.
1. Clear-Cloudy.
2. Fog-Mist.
3. Rain.
[e~882 R000300330072-1
 Approved For Release 2001/03/01 : CIA-RDP59-00882R000300330072-1
INDICATE ON THIS DIAGRAM WHAT HAPPENED
INSTRUCTIONS
Draw heavy lines to show streets or roads.
Name streets or roads, and draw arrow pointing north.
Show vehicles: -i
Show pedestrians: O----
Show railroadsc iii `i;,~m
Draw vehicles at point of accident. Use dotted lines from point of accident to point of
final rest.
Show bridges, poles, road signs, etc.
Give distance to identifying landmarks, and measurements from point of impact to edge
of roadway, point of final rest, etc.
DESCRIBE ACCIDENT BRIEFLY
Operator ^
Occupant ^
Witness ^
Other ^
FOR OFFICIAL INVESTIGATOR ONLY
NAME
CHARGES
DISPOSITION
~y q
r!a
Did you witness
Investigate At ospital or
h
6
the accident?
at scene2
d
octor's oftice7
Elsewhere?_____________
___
Were photo-
gra graphs taken? b -
Was first aid
dere ?
d
Time investi- Sl P. A. M M ~ ,
Z .. . li
lJ_
gation began?
L Is investigation
complete?.
SIGNATURE
lam(
~~
Rank
Bad g
No.
g
Depart ll pr
twee
o el s
a
1 : CIA-RDP59-00882?-0p?000.-1, 1Q-q
 1
2
prove&`P8fr 1 teas
1. Straight through.
2. Overtaking.
3. Forward from parking space.
4. Backward from parking space.
5. Other backing.
6. Right turn.
7. Left turn.
8. U-turn.
9. Slow down or stop.
10. Stopped in traffic.
11. Pafloed.
12.
Check also if a plies
1. Avoiding pedestrian.
2. Avoiding other vehicle.
3. Skidded.
4. Crowded off roadway.
5. Ran off roadway.
I
E
H
6. Lost control.
7. Car ran away-No driver.
1
2
3
Violations by Operators
1. Exceeding speed limit.
2. Speed too great for conditions.
3. Improper passing-Hill.
4. Improper passing-Curve.
5. Improper passing-Intersec'n.
6. Improper passing-Streetcar.
7. Other improper passing (exp.).
8. Wrong side of road.
9. Did not have right of way.
10. Failed to signal or imp. signal.
11. Imp, turn-Wide right turn.
12. Same-Cut corner on left turn.
13. Same-Turn from wrong lane.
14. Other improper turning.
15. Imp. start from parked posit'n.
16. Following too closely.
17. Disregarded officer.
18. Disregarded automatic signal.
19. Disregarded STOP sign.
20. Disregarded SLOW sign.
21. Failed to stop at through
highway-No sign.
22. Drove through safety zone.
23. Operating without lights.
24. Improper parking.
25. Failed to set out flags or flares.
26. Failed to dim headlights.
27. Other violations-Explain.
28. No. violations.
1. Intoxicated.
2. Had been drinking.
3. Had physical defect.
What?
4. Asleep.
5. Fatigued.
6. Inattentive.
7. Confused by traffic.
8. Apparently normal.
9.
1
2
3
Condition of Vehicles
1. Lights defective.
2. Brakes defective.
3. Steering defective.
4. Puncture or blowout.
5. Motor trouble.
6. No apparent defects.
7.
Not
Work-
in{
Work.
log
1. R. R. crossing-Gates.
2. Officer or watchman.
3. Automatic signals.
4. Flashing beacon.
5. STOP signs.
6. SLOW signs.
7. Other warning signs.
8. Roadway lines.
9. No control present.
10.
Surface of Road
1. Dry.
2. Wet.
3. Snowy-Icy.
4. Muddy.
5. Oily.
6.
Check also if applies
1. Slippery.
2. Roadway under repair.
3. Obstruction not lighted.
4. Loose material.
5. Holes in road.
6. Soft or low shoulders.
2R00dt3YJ`--1
1. Crossing at intersection-
(a) With signal.
(b) Against signal.
(c) No signal.
(d) Diagonally.
2. Crossing between intersections.
(a) Coming from behind parked car
(b) Not coming from behind par. car
3. Crossing rural highway.
4. Walking in road-With traffic.
5. Walk. in road-Against traffic.
6. Playing in road or street.
7. Working in road or street.
8, Riding or hitching on vehicle.
9. Waiting for or getting on or off
streetcar-No safety zone.
10. Same-Safety zone.
11. Getting on or off other vehicle.
12. Lying in roadway.
13. Not in street or roadway.
14.
1. Intoxicated.
2. Had been drinking.
3. Had physical defect.
What?
4. Confused by traffic.
5. Inattentive.
6. Apparently normal.
7.
Location of Accident
Check one:
1. RJmlgew-p road iggIrrwiiar.-
2. Alley or driveway intersection.
3. Railroad crossing.
4. Bridge, culvert, overpass.
5. Underpass.
6. Other.
Check one:
1. Straightaway.
2. Slight curve.
3. Sharp curve.
4. Winding road.
Check one:
1. Level.
2. Upgrade.
3. Downgrade.
4. Hill crest.
Approved For Release 2001/03/01 : CIA-RDP59-00882R000300330072-1