BTS-0601B C3RS Report Form-NJT

C³RS Report Form OMB NO: 2139-0010

(NJT Employees) EXP. DATE: xx/xx/13

C3RS Receipt Number:____________________________ C3RS Date/Time Stamp:________________________
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 2139-0010. 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, 1200 New Jersey Avenue SE, Room E36-E14, Washington, D.C. 20590 or e-mail: [email protected].
Incident Description
Please provide your name and at least one telephone number where a C3RS rail safety analyst can contact you to discuss your report, if needed. Indicate the best time to call and if you authorize BTS to leave a voice mail message on your answering service. Please provide an address to receive notice which will serve as confirmation of your report.
DATE OF OCCURRENCE TIME OF OCCURENCE (24 HR.) Division Line Segment ____________________ __________________________ □ HOBOKEN _______________________________ □ NEWARK MP or YaRD NAME ___________________________________________________ _______________________________
ADDRESS/PO BOX ________________________________________
CITY _____________________________ STATE _______ ZIP _________ JOB TITLE ________________________________
PRIMARY	PHONE NUMBER (______) ______ - ________ 	BEST TIME TO CALL __________________ 	CAN BTS LEAVE A VOICE MAIL MESSAGE? □ YES □ NO
ALTERNATE	 (______) ______ - ________ 	__________________	□ YES □ NO 
Immediate Co-Workers
Please provide the name and job title of any immediate co-workers involved in an event eligible for protection from discipline. Please encourage your immediate co-worker(s) to file their own report(s) so they receive a receipt confirming their participation in this event. You may send in your reports together or separately.
NAME ____________________________________________________________ JOB TITLE__________________________________________________________ NAME ____________________________________________________________ JOB TITLE__________________________________________________________ NAME ____________________________________________________________ JOB TITLE__________________________________________________________ NAME ____________________________________________________________ JOB TITLE__________________________________________________________  NAME ____________________________________________________________ JOB TITLE__________________________________________________________ 

3-Day Work/Sleep History Information (Very Important)

3-Day Work Shift History	Shift Start Time	Incident Time	Shift End Time
Incident Shift Day
Day before Incident
2 Days before Incident
Please use military time (24-Hour clock) for work and sleep periods.
3-Day Sleep History	Sleep Start Time	Sleep End Time	Nap – Yes/No
Last Sleep before Incident Shift
Sleep Period the Day Before
Sleep Period 2 Days Before

Engine #’s: Total # of cars: # of cars in use (open):

# of MU’s: # of Multi-levels:

Event Description

Please use the space below to complete your description of the event or condition you wish to report. Remember: the more detailed your report is, the better prepared the Rail Safety Analyst Team (RSAT) member will be to conduct a thorough interview related to the event/condition. You may find the following questions useful as you think through what information to provide. In addition, please help us prevent similar incidents from occurring by providing your suggestions for counter measures. PLEASE PRINT CLEARLY.

a. What were you and your crew doing immediately prior to the close call incident?

b. What did you notice that made you think a problem was developing?

c. What factors (weather, light, terrain, equipment, human error, etc.) may have contributed to the incident?

d. What, if anything, was unusual or unfamiliar to you or your crew with respect to this job assignment?

e. If anything or anybody interfered with your ability to perform the assigned task safely, describe how.

f. What prevented this incident from becoming a more serious accident?

Please provide a drawing on page 4 depicting the incident. Use additional paper, if needed.

Event Description (continued)	Event Diagram
Please use the space below to complete your description of the event or condition you wish to report. Remember: the more detailed your report is, the better prepared the Rail Safety Analyst Team (RSAT) member will be to conduct a thorough interview related to the event/condition. You may find the following questions useful as you think through what information to provide. PLEASE PRINT CLEARLY.	Use this page for diagrams or additional information.

Use additional paper, if needed.

Event Diagram

Use this page for diagrams or additional information.

To receive protection from discipline, you must: a) call C³RS at 1.888.568.2377 (1.888.LOV.C3RS) within 48 hours of the event to file a report, b) mail the completed C³RS Report Form, postmarked within 3 calendar days of the call, not counting weekends and Federal holidays, and c) make yourself available for an interview on the event as needed.

Mail your report to: C³RS

Bureau of Transportation Statistics

P. O. Box 23295

Washington, DC 20026-3295