F RA F 6180.107 Alternative Record For Illness Claimed To Be Work-Relate

ALTERNATIVE RECORD FOR ILLNESSES CLAIMED TO BE WORK-RELATED
DEPARTMENT OF TRANSPORTATION
FEDERAL RAILROAD ADMINISTRATION (FRA)

OMB Approval No.: 2130-0500

1. Name of Reporting Railroad

2. Case/Incident No.

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

4. Employee's Date of Birth
(mm/dd/yy)

5. Employee's Gender
Male

Female

6. Employee Number or Social
Security Number

7. Date Employee was Hired
(mm/dd/yy)
9. Employee's Home Telephone
Number (with area code)

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

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

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

13. Department to Which Employee is Assigned

15. Name of Railroad Official Notified
14. Date on Which Employee or Representative
Notified Company Personnel of Condition (mm/dd/yy)

16. Title of Railroad Official Notified

17. Nature of Claimed Illness

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

18.b. Location of Supporting Documentation

19. Narrative

20. Preparer's Name

21. Preparer's Title

22. Preparer's Telephone
Number (with area code)

23. Date the Log Entry
Was Completed (mm/dd/yy)

QUESTIONS AND ANSWERS

Q1. The only information provided to the railroad was the employee's name and social security 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.
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 6180.107 (March 2003)