FRA F 6180.55a Railroad Injury and Illness Summary (Continuation Sheet)

RAILROAD INJURY AND ILLNESS SUMMARY

DEPARTMENT OF TRANSPORTATION
1. Name of Reporting Railroad

5b.
Day

5h.
Drug/
Alcohol Test
A
D

5j.
Physical
Act

5i.
Injury
Illness
Code

OMB Approval No.: 2130-0500

2. Alphabetic Code

5a.
Accident/Injury Number

SHEET ____ OF ____

(Continuation Sheet)

FEDERAL RAILROAD ADMINISTRATION (FRA)

5c.
Time
of Day

3. Report Month

5d.
County

5k.
Location

4. Report Year

5e.
State

5l.
Event

5m.
Result

5s. Latitude (optional)

5n.
Cause

5o.
Number of
Days Away
From Work

5p.
Number of
Days
Restricted

5f.
Type
Person/
Job Code

5q.
Exposure to
Hazmat

5g.
Age

5r.
Special Case
Codes

5t. Longitude (optional)

5u. Narrative (Up to 250 Characters)

5a.
Accident/Injury Number

5b.
Day

5h.
Drug/
Alcohol Test
A
D

5j.
Physical
Act

5i.
Injury
Illness
Code

5c.
Time
of Day

5d.
County

5k.
Location

5e.
State

5l.
Event

5m.
Result

5s. Latitude (optional)

5n.
Cause

5o.
Number of
Days Away
From Work

5p.
Number of
Days
Restricted

5f.
Type
Person/
Job Code

5q.
Exposure to
Hazmat

5g.
Age

5r.
Special Case
Codes

5t. Longitude (optional)

5u. Narrative (Up to 250 Characters)

5a.
Accident/Injury Number

5b.
Day

5h.
Drug/
Alcohol Test
A
D

5j.
Physical
Act

5i.
Injury
Illness
Code

5s. Latitude (optional)

5c.
Time
of Day

5k.
Location

5d.
County

5e.
State

5l.
Event

5m.
Result

5n.
Cause

5o.
Number of
Days Away
From Work

5p.
Number of
Days
Restricted

5f.
Type
Person/
Job Code

5q.
Exposure to
Hazmat

5r.
Special Case
Codes

5t. Longitude (optional)

5u. Narrative (Up to 250 Characters)

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).
FORM FRA F 6180.55a (Revised March 2003)

5g.
Age