Form BTS-0601 C3RS Report Form

C³RS Report Form OMB NO: XXXX-XXXX

EXPIRATION DATE: XX-XX-200X

C3RS Receipt Number:
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is xxxx-xxxx. Public reporting of a close call is estimated to take approximately 30 minutes, including the time for reviewing instructions, completing and reviewing the report. Reporting any information to the Confidential Close Calls Reporting System (C3RS) is voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: C3RS Data Collection Officer, Demetra Collia, US DOT/ BTS, RTS-34, Room 3430, 400 7th Street, SW, Washington, D.C. 20590 or e-mail: [email protected]. Please provide your name and at least one telephone number where a C3RS interviewer can contact you to discuss your report, if needed. Indicate the best time to call. Please provide an address to receive the time-stamped postcard, which will serve as confirmation of your report. The details of your report will be stored in a secure database.
DATE OF OCCURRENCE _____________________		LOCAL TIME (24 HR. CLOCK) ________________________		(SPACE RESERVED FOR C3RS DATE/TIME STAMP)
MILEPOST FOR OCCURRENCE _____________________
PRIMARY	PHONE NUMBER (_______)______-________ 		BEST TIME TO CALL __________________________ 		TIME ZONE Eastern Central Mountain Pacific
ALTERNATE	 (_______)______-________ 		__________________________ 		Eastern Central Mountain Pacific
NAME _________________________________________________________________ 					JOB TITLE ____________________________________
ADDRESS/PO BOX ______________________________________________________ 
_______________________________________________________________________ 
CITY ______________________________________ STATE _____ ZIP ____________ 
Immediate Co-Workers
Please provide the name and job title of any immediate co-workers involved in an event eligible for protection from discipline. Since no names or identifying information will be retained in C3RS, the only record of the immediate co-worker’s involvement will be returned to you. Please encourage your immediate co-worker(s) to file their own report so they receive a receipt confirming their participation in this event. You can file your reports together or separately.

NAME _________________________________________	JOB TITLE______________________________	PHONE # (_______)______-________
NAME _________________________________________	JOB TITLE______________________________	PHONE # (_______)______-________
NAME _________________________________________	JOB TITLE_____________________________	PHONE # (_______)_______-________

Event Description
Please use the space below to continue your description of the event or condition you wish to report. Use the topics below you feel are relevant and anything else important to discuss the event. Use additional paper, if needed.
How did the event arise? How was the event discovered? What factors contributed to the event?	What safety consequences could this event have resulted in? What prevented an accident from taking place? What corrective actions would you recommend?

Use additional paper, if needed.

Event Description continued
Please use the space below to continue your description of the event or condition you wish to report. Use the topics below you feel are relevant and anything else important to discuss the event. Use additional paper, if needed.
How did the event arise? How was the event discovered? What factors contributed to the event?	What safety consequences could this event have resulted in? What prevented an accident from taking place? What corrective actions would you recommend?

Use additional paper, if needed.

The information you provide will be used for statistical purposes only. In accordance with the BTS confidentiality statute (49 U.S.C. 111 (k)) and the Confidential Information Protection provisions of Title V, Subtitle A, Public Law 107-347, your responses will be kept confidential and will not be disclosed in identifiable form to anyone other than BTS employees or BTS agents such as telephone interviewers. In accordance with these confidentiality statutes, only statistical and non-identifying data will be made publicly available through reports. By law, every BTS employee and BTS agent has taken an oath of confidentiality and is subject to a jail term of up to 5 years, a fine of up to $250,000, or both if he or she discloses ANY identifiable about the respondent. BTS will not release to FRA or any other public or private entity any information that might reveal the identity of individuals or organizations mentioned in close call reports.

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