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| Inspection Nr | 111479093 |
| Investigation Nr | 170250500 |
| Line Nr | 1 |
| Age | |
| Sex | |
| Nature of Injury | Concussion |
| Part of Body | Head |
| Source of Injury | Motor Vehicle (Hwy) |
| Event Type | Struck Against |
| Environmental Factor | Weather, Earthquake, Etc. |
| Human Factor | Misjudgment, Haz. Situation |
| Occupation | Occupation not reported |
| Degree of Injury | Fatality |
| Task Assigned | Task regularly assigned |
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