C-25.1, r. 2 - Regulation respecting the form of offence reports

Schedule Disposition versions

2012-09-01

SCHEDULE VII

(s. 17, par. 6)

SUPPLEMENT TO AN OFFENCE REPORT – MODEL 4

Supplement to an offence report
(additional page)
This page may be used for: 	- The continuation of E.
	- An additional statement of facts (section F) by officers or persons different from those who presented a report on the preceding page.
	- The continuation of F.
MODEL 4
ORIGIN
Department, municipality, public body or other authority				Record No.
Name and address of person responsible					Event code

RELEVANT FACTS AND ACTIONS
Check off the appropriate box
c Continuation of E
c New section F
c Continuation of F

LIGHTING
Day
1  c Daylight
2  c  Semi-darkness
Night
3   c Lighted highway
4   c Unlighted highway
WEATHER
5   cClear
6   c Cloudy
7   c Fog
8   c Rain
9   c Sleet
10 c Snow
ZONE
11 c School
12 c Residential
13 c Commercial
14 c Industrial
15 c Rural
16 c Park
ROADWAY
Type
17 c Concrete
18 c Asphalt
19 c Gravel
20 c Dirt
Condition
21 c Dry
22 c Wet
23 c Snow
24 c Ice
25 c Mud
26 c Construc.
PRESENCE ON ROAD
27 c None
28 c Veh. same direction
29 c Veh. opp. direction
30 c Veh. inters. road
31 c Pedestrian(s)
32 c Cyclist(s)
TYPE OF VEHICLE
41 c Automobile
42 c Light truck
43 c Truck
44 c Truck tractor
45 c Vehicle transporting hazardous materials
46 c Specialized mobile equipment
47 c Specialized vehicle
48 c Bus
49 c School bus
50 c Minibus
51 c Taxi
52 c Emergency veh.
53 c Motorcycle
54 c Moped
55 c Recreational veh.
56 c Sowmobile
57 c Bicycle
99 c Other
RADAR DEVICE
c Moving	Make
c Stationary	Model 
1st RADAR CHECK
c Electronic	c Tuning fork
Time	km/h
	km/h
2nd RADAR CHECK
c Electronic	c Tuning fork
Time	km/h
	km/h
c In proper working order
c Certified operator
Other vehicles present in radar beam		c Yes	c No
c Visual estimate
c No source of interference
Distance at which the radar device clocked vehicle speed ____________________metres
			c Continued on another page
SIGNATURE
I have personally observed the facts mentioned in 		c A	c B	c C	c D	c E	c F
c Peace officer 	or	c Person responsible for enforcement of the law
Surname and given name (in block letters)
Officer’s No.	Date (Y-M-D)
Signature
SIGNATURE
I have personally observed the facts mentioned in 		c A	c B	c C	c D	c E	c F
c Peace officer 	or	c Person responsible for enforcement of the law
Surname and given name (in block letters)
Officer’s No.	Date (Y-M-D)
Signature
*CR-89A-3 (93-10)	(From prescribed by regulation to be used as documentary evidence)

O.C. 1210-97, Sch. VII.