Orami01/Test3 · Datasets at Hugging Face

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See 49 C.F.R. 225.7 (b).
OMB approval expires 02/28/2014
33. Name of Railroad Official 34. Signature 35. Telephone Number 36. Date initially
signed/completed
32. Was this accident/incident reported to the FRA? Yes No
Nonfatal Fatal
5. Other Railroad or Entity
1. Date of Accident/Incident (YY/MM/DD) 2. Time of Accident/Incident AM
PM
4. Incident Number
6. Incident Number
7. Railroad or Other Entity Responsible for Track Maintenance 8. Incident Number
9. Type of Accident/Incident (Derailment, Collision, Obstruction, Other)
10. Number of Hazmat Cars Damaged or Derailed 11. Number of Hazmat Cars Releasing Product
12. Subdivision 13. Nearest City/Town 14. County 15. State
16. Milepost (to nearest tenth) 17. Specific Site
18. Speed Actual
Estimated
19. Train/Job Number
20. Type of Equipment (Freight, Passenger, Yard/Switching, etc.) 21. Type of Track (Main, Yard, Siding, Industry)
22. Total Locomotive Units in Train
26. Equipment Damage (in dollars)
28. Primary Cause
23. Total Locomotives Derailed
29. Contributing Cause
27. Track, Signal, Way & Structure Damage (in dollars)
24. Total of Cars in Equipment Consist 25. Total Cars Derailed
EMPLOYEE INFORMATION
RAILROAD EMPLOYEE INJURY AND/OR ILLNESS RECORD
DEPARTMENT OF TRANSPORTATION
FEDERAL RAILROAD ADMINISTRATION (FRA) OMB No. 2130-0500
FORM FRA F 6180.98 (Rev. 08/10) OMB approval expires 02/28/2014
ACTIVITY/INCIDENT/EXPOSURE DESCRIPTION
1. Railroad 2. Case/Incident Number
3. Last Name, First Name, Middle Initial 4. Date of Birth 5. Sex (M/F) 6. Employee ID Number 7. Date Hired
HOME
ADDRESS:
ESTABLISHMENT/
FACILITY WHERE
EMPLOYEE
NORMALLY REPORTS:
18. Job Title
8. Street Address (include Apt. No.)
13. Name of Facility
14. Street Address
9. City 10. State 11. ZIP 12. Home Telephone No.
(include area code)
15. City 16. State 17. ZIP
19. Department Assigned To
NOTE: This report is part of the reporting railroad's accident report pursuant to the accident reports statute and, as such shall not "be admitted as evidence
or used for any purpose in any suit or action for damages growing out of any matter mentioned in said report. . . ." 49 U.S.C. 20903.
See 49 C.F.R. 225.7 (b).
LOCATION WHERE
ACCIDENT/
INCIDENT/
EXPOSURE
OCCURRED:
COMPANY
NOTIFICATION:
20. Specific Site
21. City 22. County 23. State 24. ZIP
25. Is this on your premises?
Yes No
26. Date of Occurrence 27. Time Shift Began AM
PM
28. Time of Occurrence AM 29. Was person on duty?
PM
AM
PM
31. Time that Employee Notified
Company Personnel of Condition
30. Date that Employee Notified
Company Personnel of Condition
32. Person Notified
Yes No
33. Describe the general activity this person was engaged in prior to injury/illness.
34. Describe all factors associated with this case that are pertinent to an understanding of how it occurred. Include a discussion of the sequence of
events leading up to it, and the tools, machinery, processes, material, environmental conditions, etc., involved.
This collection of information is mandatory under 49 CFR 225, and is used by FRA to monitor national rail safety. Public reporting burden is
estimated to average 1 hour per response, including the time for reviewing instructions, searching existing databases, gathering and
maintaining the data needed, and completing and reviewing the collection of information. The information collected is a matter of public
record, and no confidentiality is promised to any respondent. Please note that an agency may not conduct or sponsor, and a person is not
required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number for this
collection is 2130-0500.
INJURY/CONDITION INFORMATION
35. Describe in detail the injury/condition that this person sustained. Include a discussion of the body parts affected. If this is a recurrence, list date
of last occurrence.
36. Identify all persons and organizations used to evaluate and/or treat condition. (Include facility, provider, and address)
37. Describe all procedures, medications, therapy, etc., used/recommended for the treatment of condition:
40. Has this employee been provided an opportunity to review his or her file?
41. Preparer’s Name 42. Preparer’s Title 43. Telephone Number 44. Date initially
signed/completed
Yes No
39. If any of the above consequences occurred, the injury/condition is almost always reportable to FRA on Form FRA F 6180.55a. If you believe this case
does not meet the reporting criteria, you must give a brief explanation below of the basis for this decision. Was the case reported? Yes No
38. Check any of the following consequences resulting from this injury/condition:
Death. Date of: _______________
Restriction of work. Reportable days of restricted activity: ____________ as of: ____________
Occupational illness. Date of initial diagnosis:
Instructions to obtain prescription medication, or receipt of prescription medication.

See 49 C.F.R. 225.7 (b).

OMB approval expires 02/28/2014

33. Name of Railroad Official 34. Signature 35. Telephone Number 36. Date initially

signed/completed

32. Was this accident/incident reported to the FRA? Yes No

Nonfatal Fatal

5. Other Railroad or Entity

1. Date of Accident/Incident (YY/MM/DD) 2. Time of Accident/Incident AM

PM

4. Incident Number

6. Incident Number

7. Railroad or Other Entity Responsible for Track Maintenance 8. Incident Number

9. Type of Accident/Incident (Derailment, Collision, Obstruction, Other)

10. Number of Hazmat Cars Damaged or Derailed 11. Number of Hazmat Cars Releasing Product

12. Subdivision 13. Nearest City/Town 14. County 15. State

16. Milepost (to nearest tenth) 17. Specific Site

18. Speed Actual

Estimated

19. Train/Job Number

20. Type of Equipment (Freight, Passenger, Yard/Switching, etc.) 21. Type of Track (Main, Yard, Siding, Industry)

22. Total Locomotive Units in Train

26. Equipment Damage (in dollars)

28. Primary Cause

23. Total Locomotives Derailed

29. Contributing Cause

27. Track, Signal, Way & Structure Damage (in dollars)

24. Total of Cars in Equipment Consist 25. Total Cars Derailed

EMPLOYEE INFORMATION

RAILROAD EMPLOYEE INJURY AND/OR ILLNESS RECORD

DEPARTMENT OF TRANSPORTATION

FEDERAL RAILROAD ADMINISTRATION (FRA) OMB No. 2130-0500

FORM FRA F 6180.98 (Rev. 08/10) OMB approval expires 02/28/2014

ACTIVITY/INCIDENT/EXPOSURE DESCRIPTION

1. Railroad 2. Case/Incident Number

3. Last Name, First Name, Middle Initial 4. Date of Birth 5. Sex (M/F) 6. Employee ID Number 7. Date Hired

HOME

ADDRESS:

ESTABLISHMENT/

FACILITY WHERE

EMPLOYEE

NORMALLY REPORTS:

18. Job Title

8. Street Address (include Apt. No.)

13. Name of Facility

14. Street Address

9. City 10. State 11. ZIP 12. Home Telephone No.

(include area code)

15. City 16. State 17. ZIP

19. Department Assigned To

NOTE: This report is part of the reporting railroad's accident report pursuant to the accident reports statute and, as such shall not "be admitted as evidence

or used for any purpose in any suit or action for damages growing out of any matter mentioned in said report. . . ." 49 U.S.C. 20903.

See 49 C.F.R. 225.7 (b).

LOCATION WHERE

ACCIDENT/

INCIDENT/

EXPOSURE

OCCURRED:

COMPANY

NOTIFICATION:

20. Specific Site

21. City 22. County 23. State 24. ZIP

25. Is this on your premises?

Yes No

26. Date of Occurrence 27. Time Shift Began AM

PM

28. Time of Occurrence AM 29. Was person on duty?

PM

AM

PM

31. Time that Employee Notified

Company Personnel of Condition

30. Date that Employee Notified

Company Personnel of Condition

32. Person Notified

Yes No

33. Describe the general activity this person was engaged in prior to injury/illness.

34. Describe all factors associated with this case that are pertinent to an understanding of how it occurred. Include a discussion of the sequence of

events leading up to it, and the tools, machinery, processes, material, environmental conditions, etc., involved.

This collection of information is mandatory under 49 CFR 225, and is used by FRA to monitor national rail safety. Public reporting burden is

estimated to average 1 hour per response, including the time for reviewing instructions, searching existing databases, gathering and

maintaining the data needed, and completing and reviewing the collection of information. The information collected is a matter of public

record, and no confidentiality is promised to any respondent. Please note that an agency may not conduct or sponsor, and a person is not

required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number for this

collection is 2130-0500.

INJURY/CONDITION INFORMATION

35. Describe in detail the injury/condition that this person sustained. Include a discussion of the body parts affected. If this is a recurrence, list date

of last occurrence.

36. Identify all persons and organizations used to evaluate and/or treat condition. (Include facility, provider, and address)

37. Describe all procedures, medications, therapy, etc., used/recommended for the treatment of condition:

40. Has this employee been provided an opportunity to review his or her file?

41. Preparer’s Name 42. Preparer’s Title 43. Telephone Number 44. Date initially

signed/completed

Yes No

39. If any of the above consequences occurred, the injury/condition is almost always reportable to FRA on Form FRA F 6180.55a. If you believe this case

does not meet the reporting criteria, you must give a brief explanation below of the basis for this decision. Was the case reported? Yes No

38. Check any of the following consequences resulting from this injury/condition:

Death. Date of: _______________

Restriction of work. Reportable days of restricted activity: ____________ as of: ____________

Occupational illness. Date of initial diagnosis:

Instructions to obtain prescription medication, or receipt of prescription medication.