FRA F 6180.61 Accident/Incident Reporting Rules Violation Report Form

OMB No. 2130-0509
U.S. Department of Transportation
Federal Railroad Administration

Accident / Incident Reporting Rules Violation Report Form

An inspection of this carrier's records disclosed the following accident/incident which should have been reported under Federal Railroad Administration Regulations (49 CFR
PART 225).
1. Name and Address of Railroad:

2. Division:

3. Viol. Report No.:

4. Place of Accident/Incident:

5. Time:

6. Date:

7. Type of Accident/Incident:
Rail Equipment

Highway Grade Crossing
Occupational Illness

Injury

8. Regulations Violated:
A. FRA Rules

B. FRA Guide

Other (Specify Under Details)
10. Line Item Number:

9. F6180.96 Report Number - Date:

11. Violation of 49 CFR:
Part

12.

Rule

Subrule

Death, Injury, or Occupational Illness
C. Occupation (if employee):

B. Type of Person:

A. Name of Person:

D. Nature of Occupational Illness or Injury and Treatment:

Transfer to Another Job

E. Employee's Occupational Illness or Injury Resulted in:
Lost Workdays

Death

Termination of Employment

Restriction of Work or Motion

Medical Treatment

Loss of Consciousness

F. Description of Injured Employee's Restriction of Work or Motion:

G. Medical Release to Duty:

H. Remarks on Medical Release:

Issued:
Effective:
I. Name, Title, and Location of Physician or Registered Professional Who Provided Medical Treatment:

13. Details of How Accident/Incident Occurred and What Made it Reportable:

14. Name of Inspector:

ID No.:

15. Signature of Inspector:

16. Date of Signature:

Public reporting burden for this information collection is estimated to average 4 hours 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 2130-0509. All responses to this
collection of information are mandatory. 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.

Form FRA F6180.61 (7/03)

OMB approval expires 11/30/2006