Form FRA F 6180.125A FRA F 6180.125A Protocol for Railway Personnel Involved in Suicide Incid

Protocol for Railway Personnel involved in Suicide Incidents

OMB No. 2130-XXXX

Case Number	Interview Date
Relationship to Incident  Train Driver  Conductor  Other Specify:	ID Number of Interviewer
	Interview Venue
Comments:	Time Interview Started ______________ Time Interview Ended ______________

1. Train driver details:

a. Name:

b. Age:

c. Gender:

d. Race/Ethnicity:

e. Years of experience with railroad:

f. No. of railroad suicides witnessed:

g. No. of other railroad deaths witnessed:

2. Train Characteristics:

a. Type: Units Pushing, Units Pulling, Standing,

b. Function: Freight, Passenger, Yard Switching, Other (mixed trains, work trains, light locomotives, single car or cut of cars)

c. Regular Time: Delayed, On time

FRA F 6180.125A (1-07)

3. Location of suicide:

a. City, State:

b. Proximity to railroad crossing: ________ miles

c. Track Class: 1, 2, 3, 4, 5, 6, unknown

4. Conditions at time of suicide:

a. Time of day: Dawn, Day, Dusk, Night

b. Weather: Clear, Cloudy, Rainy, Foggy, Sleet, Snowy, Other

c. Temperature: <25 degrees, 25 - 50 degrees, 50 – 75 degrees, >75 degrees

d. Visibility: Unlimited Somewhat limited Quite limited

Severely limited

5. Speed of train at time of impact: ________miles/hour

6. Eye-witnesses present:

a. Railway personnel: Employee on Duty, Employee Not on Duty, Contractor, Other

b. Non-railway personnel: Passenger, Bystander, Other

6a. Interviewee as eyewitness:

a. Estimated number of seconds that interviewee saw decedent prior to impact: __

b. Did decedent make eye contact with interviewee?

c. Describe interviewee’s efforts to prevent impact:

d. Describe decedent’s approach to tracks (e.g., deliberate walk, running, sitting or lying on tracks…):

e. Describe decedent's demeanor/behavior (e.g., confused, frantic,…):

7. Events following the incident:

8. Injuries sustained (other than those to decedent):

a. Railway personnel: Employee on Duty, Employee Not on Duty, Contractor, Other

b. Non-railway personnel: Passenger, Bystander, Other

9. Possible prevention mechanisms:

10. Notes:

F

Public reporting burden for this information collection is estimated to average five (5) minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. According to the Paperwork Reduction Act of 1995, 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 unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 2130-XXXX. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: Information Collection Officer, Federal Railroad Administration, 1120 Vermont Ave., N.W., Washington D.C. 20590.

RA F 6180.125A (1-07)