FRA F 6180.98 Railroad Employee Injury and/or Illness Record

RAILROAD EMPLOYEE INJURY AND/OR ILLNESS RECORD
DEPARTMENT OF TRANSPORTATION
FEDERAL RAILROAD ADMINISTRATION (FRA)

OMB Approval No.: 2130-0500

1. Railroad

2. Case/Incident Number

EMPLOYEE INFORMATION
3. Last Name, First Name, Middle Initial
HOME
ADDRESS:

4. Date of Birth

8. Street Address (include Apt. No.)

9. City

13. Name of Facility
ESTABLISHMENT/
FACILITY WHERE
EMPLOYEE
NORMALLY REPORTS: 14. Street Address
18. Job Title

5. Sex (M/F) 6. Social Security Number
10. State 11. ZIP

7. Date Hired

12. Home Telephone No.
(include area code)

15. City

16. State

17. ZIP

23. State

24. ZIP

19. Department Assigned To

ACTIVITY/INCIDENT/EXPOSURE DESCRIPTION
LOCATION WHERE
ACCIDENT/
INCIDENT/
EXPOSURE
OCCURRED:

20. Specific Site
21. City

22. County

25. Is this on your premises? 26. Date of Occurrence 27. Time Shift Began
Yes
No
COMPANY
NOTIFICATION:

AM

28. Time of Occurrence

PM

30. Date that Employee Notified
31. Time that Employee Notified
AM
Company Personnel of Condition
Company Personnel of Condition
PM

AM
PM

29. Was person on duty?
Yes
No

32. Person Notified

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.

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 6180.98 (Revised March 2003)

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:

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

Restriction of work. Reportable days of restricted activity: _________ as of: _______________

Hospitalization for treatment as an
inpatient
inpatient.

Occupational illness. Date of initial diagnosis:

Multiple treatments or therapy sessions.

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

Loss of consciousness.

Death. Date of: _______________

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.
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

40. Has this employee been provided an opportunity to review his or her file?
41. Preparer's Name

42. Preparer's Title

Yes

No
43. Telephone Number

44. Date