Orami01/Test3 · Datasets at Hugging Face

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Missed a day of work or next shift. Reportable days absent from work: ____________ as of: ____________
Significant injury/illness, one meeting specific case criteria, or a covered data case.
Medical treatment. This includes any medical care or treatment beyond “first aid” that is given, or should have been given, regardless of
who provided the treatment. “First Aid” treatment is limited to very simple procedures, e.g., application of a bandaid on minor scratches,
cuts, abrasions, etc.
Transfer to another job or termination of employment.
Hospitalization for treatment as an
inpatient.
Multiple treatments or therapy sessions.
Loss of consciousness.
DEPARTMENT OF TRANSPORTATION
FEDERAL RAILROAD ADMINISTRATION (FRA)
ALTERNATIVE RECORD FOR ILLNESSES CLAIMED TO BE WORK-RELATED
1. Name of Reporting Railroad
19. Narrative
OMB No. 2130-0500
FORM FRA F 6180.107 (Rev. 08/10)
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
75 minutes 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.
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).
OMB approval expires 02/28/2014
Q1. The only information provided to the railroad was the employee’s name and Employee ID Number. Further attempts to
complete the other data elements were rejected by the employee and/or his or her attorney. Does this meet FRA requirements?
A1. Yes. The railroad should continue to complete all the data elements when the information becomes available and should make
a good faith effort to obtain the information. However, the railroad is not expected to continue this effort past December 1 of the
year that follows the date on which the railroad first received a claim of the illness.
2. Case/Incident Number
3. Employee’s Name (First, middle, last)
4. Employee’s Date of Birth
(mm/dd/yy)
5. Employee’s Gender
9. Employee’s Home Telephone
Number (with area code)
10. Name of Facility Where Railroad Employee Normally Reports to Work
8. Employee’s Home Address (include street address, city, State and ZIP code)
13. Department to Which Employee is Assigned
14. Date on Which Employee or Representative
Notified Company Personnel of Condition (mm/dd/yy)
17. Nature of Claimed Illness
18.a. Custodian of Documents (Name, Title, and Address)
15. Name of Railroad Official Notified 16. Title of Railroad Official Notified
QUESTIONS AND ANSWERS
20. Preparer’s Name 21. Preparer’s Title 22. Preparer’s Telephone
Number (with area code) 23. Date initially signed/completed
18.b. Location of Supporting Documentation
12. Job Title of Railroad Employee
11. Location, or Last Known Facility, Where Employee Reports to Work
Male Female
6. Employee ID Number 7. Date Employee was Hired
(mm/dd/yy)
18. Supporting Documentation
HIGHWAY USER INJURY INQUIRY FORM
DEPARTMENT OF TRANSPORTATION
Federal Railroad Administration (FRA) OMB No. 2130-0500
PART I – Highway Rail-Grade Crossing Accident/Incident (To be completed by reporting railroad)
1a. Date of Accident/Incident (mm/dd/yyyy) 1b. Time of Accident/Incident AM PM
2a. Name of Railroad


2b. Alphabetic Code 3. Railroad Accident/Incident Number
4. U.S. DOT Grade Crossing Identification Number
5. Highway Name or Number 6. City (if in a city) 7. County 8. State Abbr.
PART II - Highway User Statement (To be completed by highway user or highway user's representative)
9a. Highway User’s Last Name

9b. First Name 9c. Middle Initial 10. Highway User 's Age
11. Highway User's Telephone (Primary) 12. Highway User's Telephone (Secondary) 13. Highway User's E-mail Address
14. Highway User's Mailing Address
15a. Did you suffer an injury, or injuries, as a result of the highway-rail grade accident/incident described above? Yes No
15b. Narrative Description: If you answered "Yes" to 15a., please describe the nature and severity of your injury, or injuries, the event(s) that caused the injury, or
injuries, and any other relevant information. You may continue the Narrative Description on back of form.


16a. As a result of your injury, or injuries, caused by the highway rail-grade crossing accident/incident, did you (please check all that apply and complete the Narrative
Description in 16b.):
(i) Receive medical treatment beyond first aid (i.e. prescription medication or stitches)
(ii) Lose consciousness
(iii) Suffer a fractured or cracked bone, or a punctured eardrum diagnosed by a physician or other licensed health care provider
(iv) Receive transportation from the highway rail-grade crossing accident/incident to a medical facility via emergency medical transportation (EMT) (i.e. ambulance)
16b. Narrative Description: (1) Describe any medical treatment received as a result of the accident; (2) Provide additional information about the boxes checked in
16a. above; and (3) Provide other related information. You may continue the Narrative Description on back of form.
17a. Name of Person Completing Part II

Check Appropriate Box:
Highway User
Highway User's Representative
17b. Highway User’s Representative’s
Name (if applicable):
Telephone Number:
Relationship:
18. Signature 19. Date
Note: Railroads are required to send this form under 49 CFR 225.
FORM FRA F 6180.150 (Rev. 08/10) NOTE THAT RAILROAD MUST REPORT ALL REPORTABLE CASUALTIES ON FORM FRA F 6180.55a

OMB approval expires 02/28/2014

Missed a day of work or next shift. Reportable days absent from work: ____________ as of: ____________

Significant injury/illness, one meeting specific case criteria, or a covered data case.

Medical treatment. This includes any medical care or treatment beyond “first aid” that is given, or should have been given, regardless of

who provided the treatment. “First Aid” treatment is limited to very simple procedures, e.g., application of a bandaid on minor scratches,

cuts, abrasions, etc.

Transfer to another job or termination of employment.

Hospitalization for treatment as an

inpatient.

Multiple treatments or therapy sessions.

Loss of consciousness.

DEPARTMENT OF TRANSPORTATION

FEDERAL RAILROAD ADMINISTRATION (FRA)

ALTERNATIVE RECORD FOR ILLNESSES CLAIMED TO BE WORK-RELATED

1. Name of Reporting Railroad

19. Narrative

OMB No. 2130-0500

FORM FRA F 6180.107 (Rev. 08/10)

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

75 minutes 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.

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).

OMB approval expires 02/28/2014

Q1. The only information provided to the railroad was the employee’s name and Employee ID Number. Further attempts to

complete the other data elements were rejected by the employee and/or his or her attorney. Does this meet FRA requirements?

A1. Yes. The railroad should continue to complete all the data elements when the information becomes available and should make

a good faith effort to obtain the information. However, the railroad is not expected to continue this effort past December 1 of the

year that follows the date on which the railroad first received a claim of the illness.

2. Case/Incident Number

3. Employee’s Name (First, middle, last)

4. Employee’s Date of Birth

(mm/dd/yy)

5. Employee’s Gender

9. Employee’s Home Telephone

Number (with area code)

10. Name of Facility Where Railroad Employee Normally Reports to Work

8. Employee’s Home Address (include street address, city, State and ZIP code)

13. Department to Which Employee is Assigned

14. Date on Which Employee or Representative

Notified Company Personnel of Condition (mm/dd/yy)

17. Nature of Claimed Illness

18.a. Custodian of Documents (Name, Title, and Address)

15. Name of Railroad Official Notified 16. Title of Railroad Official Notified

QUESTIONS AND ANSWERS

20. Preparer’s Name 21. Preparer’s Title 22. Preparer’s Telephone

Number (with area code) 23. Date initially signed/completed

18.b. Location of Supporting Documentation

12. Job Title of Railroad Employee

11. Location, or Last Known Facility, Where Employee Reports to Work

Male Female

6. Employee ID Number 7. Date Employee was Hired

(mm/dd/yy)

18. Supporting Documentation

HIGHWAY USER INJURY INQUIRY FORM

DEPARTMENT OF TRANSPORTATION

Federal Railroad Administration (FRA) OMB No. 2130-0500

PART I – Highway Rail-Grade Crossing Accident/Incident (To be completed by reporting railroad)

1a. Date of Accident/Incident (mm/dd/yyyy) 1b. Time of Accident/Incident AM PM

2a. Name of Railroad

2b. Alphabetic Code 3. Railroad Accident/Incident Number

4. U.S. DOT Grade Crossing Identification Number

5. Highway Name or Number 6. City (if in a city) 7. County 8. State Abbr.

PART II - Highway User Statement (To be completed by highway user or highway user's representative)

9a. Highway User’s Last Name

9b. First Name 9c. Middle Initial 10. Highway User 's Age

11. Highway User's Telephone (Primary) 12. Highway User's Telephone (Secondary) 13. Highway User's E-mail Address

14. Highway User's Mailing Address

15a. Did you suffer an injury, or injuries, as a result of the highway-rail grade accident/incident described above? Yes No

15b. Narrative Description: If you answered "Yes" to 15a., please describe the nature and severity of your injury, or injuries, the event(s) that caused the injury, or

injuries, and any other relevant information. You may continue the Narrative Description on back of form.

16a. As a result of your injury, or injuries, caused by the highway rail-grade crossing accident/incident, did you (please check all that apply and complete the Narrative

Description in 16b.):

(i) Receive medical treatment beyond first aid (i.e. prescription medication or stitches)

(ii) Lose consciousness

(iii) Suffer a fractured or cracked bone, or a punctured eardrum diagnosed by a physician or other licensed health care provider

(iv) Receive transportation from the highway rail-grade crossing accident/incident to a medical facility via emergency medical transportation (EMT) (i.e. ambulance)

16b. Narrative Description: (1) Describe any medical treatment received as a result of the accident; (2) Provide additional information about the boxes checked in

16a. above; and (3) Provide other related information. You may continue the Narrative Description on back of form.

17a. Name of Person Completing Part II

Check Appropriate Box:

Highway User

Highway User's Representative

17b. Highway User’s Representative’s

Name (if applicable):

Telephone Number:

Relationship:

18. Signature 19. Date

Note: Railroads are required to send this form under 49 CFR 225.

FORM FRA F 6180.150 (Rev. 08/10) NOTE THAT RAILROAD MUST REPORT ALL REPORTABLE CASUALTIES ON FORM FRA F 6180.55a

OMB approval expires 02/28/2014