Form FRA-F-6180.117 Report of Railroad Trespasser Death

R

OMB # 2130-0563

EPORT OF RAILROAD TRESPASSER DEATH

State: County: Fatality Date: Fatality Time:

Railroad: Location:

Age at death:

Circumstance:

If any of the above information is incorrect, please cross out and enter correct information.

P ublic reporting burden for this information collection is estimated to average 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 2130-0563. 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: Robert Brogan, Information Collection Officer, Federal Railroad Administration, 1200 New Jersey Ave., SE, Washington DC 20590 or transmitted electronically to the Federal Railroad Administration at [email protected] .

INFORMATION BELOW TO BE PROVIDED BY CME OR CORONER

Please respond to the questions below regarding the trespasser death referenced in the information above. Once completed, please return this form in the enclosed, self-addressed envelope. DO NOT SEND THIS FORM TO FRA. Thank you for your assistance.

North American Management is the only party authorized to view this data in its raw format. North American Management will provide summary reports to FRA. FRA will not have access to the raw data you submit. The additional data you provide for this specific investigation will generally only be released to the FRA or made public via generalized, statistical, summary reports.  If any specific information is provided to the FRA, it will be anonymous and any personal identifying information will be removed.

Gender:

• Male

• Female

Ethnicity (please select one of the following):

• American Indian

• Asian

• Black or African American

• Caucasian

• Hispanic/Latino

• Pacific Islander

Decedent’s Home Address:

Street Address _____________________________________________________

City ________________________________ State ______ Zip ___________

Was alcohol a factor?

• Yes

• No

Were drugs a factor?

• Yes

• No

Was the incident a suicide?

• Yes

• No

Incident description. Please offer any information on what the deceased was doing or trying to do at the time of the incident in the space provided below (e.g., getting on or off train, sleeping, walking, etc.).

FRA – F – 6180.117 (rev. 1-12)