FRA F 6180.4a MPE Safety Concern Recommendation Report

OMB No. 2130-0565

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Public reporting burden for this information collection is estimated to average 60 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 2130-0565. 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, 1200 New Jersey Ave., N.W., Washington D.C. 20590

U.S. Department of Transportation

MP&E SAFETY CONCERN AND RECOMMENDATION REPORT

Federal Railroad Administration
Inspector(s) Name:

Inspector ID:

Date:

Region:

Built Date:

Type: (e.g. B, CH, AC, etc. use code from F6180.96 / RISPC table)

Name of Builder and/or Owner:

Location of Builder and/or Owner: (City & State)

Were Concern(s) Recorded On F6180.96:
Initial:

Number:
If Yes, Indicate Inspector Initials Followed by Inspection Report No.(s):

Approximate Number Of Units With

0

Reporting Marks:

If Known, Approximate Number Of Units In Service With The Concern(s) Described Below:

CFR Section And Text Reference: (Cite Complete CFR Section, TB, and Corresponding Text Description)

Description Of Concern(s):

Cite Any Safety Concerns, Known History Of Injuries/Fatalities/Derailments, etc. Associated With This Issue: ( Names, Dates, Location, etc.)

Inspector Recommendation(s):

FRA F 6180.4a (11/04)

FRA Control No.:

Yes

No

OMB No. 2130-0565

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