HomeMy WebLinkAboutDamage Report08/24/2007 13:16 3054165444
MIAMI FIRE RESCUE
PAGE 03/05
ACCIDENT DATA
City of Miami
VEHICLE/PROPERTY DAMAGE REPORT
See Instructions for completion on reverse side.
1. Driver/Employee Name:
Juan B. Tavarez
0. Department
Fire
6. Social Security No:
142-76-7435
9. Name of Other Party:
N/A
12. Date of Accident/Incident:
05/11/07 _
15. Location of Accident/incident:
2. Title:
Firefighter
4, Division:
E1tD
7. Vehicle/Property Type:
International Rescue #3
10, Address/Location of Other Party:
N/A
13. Time of Accident:
5. Telephone No:
305-575-5224
8- Vehicle No:
1HTMNAAM7711470017
11. Telephone No. of Other Party:
N/A
14. Police Case No:
2310 Hrs awrat;aaax 070511138882
17. Did any party receive a citation? Specify:
NA
As I was driving northbound on 17 Ave
cars were traveling southbound. So I decided to make sure I was completely iu the
northbound lane. As I approached the tree, I felt I had enough space to pass. Afte
the cab passed, the vehicle was stricken by the tree.
19. Sketch Accident/Incident:
SW 17 Ave/ Micanopy Ave
18. Weather conditions at the time of the accident/incident
Night- Clear
8. Driver's description of the facts surrounding the accident/incident:
20, Time reported to supervisor:
2310 Hrs 311M
21. Person notified at Risk enagement
A7C/o
24. Person at Risk Management r 8ponding to scene;
n s sae
25. If
response, explain:
26. Supervisor's comme t d on evidence and statements:
F.F. Tavarez is recently off probation and is not familar with all parts of the
city. He was not aware of how far this tree jutted out into the road and was
trying to maintain his place in his lane due to oncoming traffic.
WITNESS DMA
27.
WITNESS NAME
28.
ADDRESS
29.
TELEPHONE NO.
Lt. Roy Martinez
1103 NW 7 ST
305-575-5224
George Bentacourt
1103 NW 7
305-575-5224
AUTHORIZED SIGNATURES
30. Prepared
ployee's Signature
Supervisor's Signature
�-1ra
Date
-7
2o07
Date
31. Reviewed fay:
Department Director
C35
Date
PM/AL 040 Rev. 06/91 Replaces form C PM/AL 032 Supervisors vehicle Accident Report.
Distribution: Retain original In Department Fax copy: Risk Management; Photocopy: Safety Coordinator.