Form BTS-0010A UP Report Form

C3RS Report Form
(UP Employees)

OMB NO: 2139-0010
Expiration Date: 08-31-2013

C3RS Confirmation Number:
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 20 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 E36-302, Washington, D.C. 20590 or
email: [email protected]
.

Incident Details
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 C3RS 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.

Incident Date:

Incident Time (24 HR.)

Name

Sub Divsion

Job Title

Line Segment
Yard

MP

Address/PO Box
City

State
Phone Number

Zip
Best Time to Call

Time Zone

PRIMARY
ALTERNATE

Railroad Experience

Years

Experience in Craft

EST

MST

CST

PST

EST

MST

CST

PST

Years

Can Staff Leave a
Voice Message?
Yes

No

Yes

No

Job #:

Immediate Co-Workers
Please provide the name and job title of any immediate co-workers involved in the incident 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 incident.
You may send in your reports together or separately.

Name

Job Title

Name

Job Title

Name

Job Title

Name

Job Title

Name

Job Title

To receive protection from discipline, you must: a) call C3RS at 1.888.568.2377 (1.888.LOV.C3RS) within 48 hours of the incident 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 incident as needed.
Mail your report to: C3RS
Bureau of Transportation Statistics
P. O. Box 23295
Washington, DC 20026-3295
BTS-0010A

C3RS Report Form
(UP Employees)

OMB NO: 2139-0010
Expiration Date: 08-31-2013

72-Hour Work/Sleep History Information
72-hour work shift history Shift start time
Incident time
Shift end time
Incident shift day
1 day before incident
2 days before incident
Please use military time (24-Hour clock) for work and sleep periods
72-hour sleep history
Sleep start time Sleep end time Sleep quality Rest quality Nap-Yes/No Nap start/end time
Last sleep before incident
Sleep period 1 day before
Sleep period 2 days before
Train symbol:
Engine #'s:
Distributed Power Units:
Loads:

Empties:

Tons:

Length:

ft No. of Hazmat:

Weather
Clear

Cloudy

Lightning

Fog

Hail Storm

Slight Rain

Intense Rain

Conditions in Transition

Snow (on ground)

Cold

Snowing

High Winds

Hot

Light Condition
Dawn

Daylight

Dusk

Night

Limited

Less than one car length

Visibility
Unlimited
Temperature
30(F) and below

31 - 90(F)

91(F) and above

Train Activity
Stopped

En route

Switching on siding

Hold (siding for meet, M/W work, other)
Switching in yard

Lite engine movement

Remote control operation

Other

Crew Activity
Pre-departure inspection by crew
Pilot/Hostler move
Car/Bad Order Cross Haul

BTS-0010A

Switching
Other

Pre-departure inspection by others
Humping

Departure

Road Crew Lite Power Move

Arrival

C3RS Report Form
(UP Employees)

OMB NO: 2139-0010
Expiration Date: 08-31-2013

Incident Description
Please use the space below to complete your description of the incident 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
incident/condition. In addition, please help us prevent similar incidents from occurring by providing your suggestions to prevent this
incident from happening again.
You may find the following questions useful as you think through what information to provide.
What were you and your crew doing immediately prior to the close call incident?
What did you notice that made you think a problem was developing?
What factors (weather, light, terrain, equipment, human error, etc.) may have contributed to the incident?
What, if anything, was unusual or unfamiliar to you or your crew with respect to this job assignment?
If anything or anybody interfered with your ability to perform the assigned task safely, describe how.
What prevented this incident from becoming a more serious accident?
PLEASE PRINT CLEARLY, USE ADDITIONAL PAPER IF NEEDED.

The information you provide will be used for statistical purposes only. In accordance with the BTS confidentiality statute (49 U.S.C. 111 (k)) and the
Confidential Information Protection provisions of Title V, Subtitle A, Public Law 107-347, your responses will be kept confidential and will not be
disclosed in identifiable form to anyone other than BTS employees or BTS agents such as telephone interviewers. In accordance with these confidentiality
statutes, only statistical and non-identifying data will be made publicly available through reports. By law, every BTS employee and BTS agent has taken an
oath of confidentiality and is subject to a jail term of up to 5 years, a fine of up to $250,000, or both if he or she discloses ANY identifiable information
about the respondent. BTS will not release to FRA or any other public or private entity any information that might reveal the identity of individuals or
organizations mentioned in close call reports.

BTS-0010A

C3RS Report Form
(UP Employees)
Incident Diagram
Use this page for diagrams or additional information.

BTS-0010A

OMB NO: 2139-0010
Expiration Date: 08-31-2013