FRA F 6180.55 Railroad Injury and Illness Summary

Yellow = Existing item in which the wording
was either changed or expanded on the form.

RAILROAD INJURY AND ILLNESS SUMMARY

DEPARTMENT OF TRANSPORTATION
FEDERAL RAILROAD ADMINISTRATION (FRA)

1. Name of Reporting Railroad

2. Alphabetic Code

3. Report Month & Year

6. Name of Reporting Officer

7. Official Title

8. Address

9. Telephone

OMB No. 2130-0500
5. County

4. State Alphabetic Code

(Area Code) (Number)

10.

If executed within the United States, its territories, possessions, or commonwealths:
I declare (or certify, verify, or state) under penalty of perjury that the information on this form is true and correct.
Executed on _____________________ (date).
____________________________________________ (Signature).

If executed without (i.e., outside of) the United States:
I declare (or certify, verify, or state) under penalty of perjury under the laws of the United States of America that the information on this form is true and
correct.
Executed on _____________________ (date).
____________________________________________ (Signature).
OPERATIONAL DATA & ACCIDENT/INCIDENT COUNTS FOR REPORT MONTH
11. Freight Train Miles

12. Passenger Train Miles

15. Railroad Worker Hours

18.

13. Yard Switching Train Miles

16. Passenger Miles Operated

REPORTED CASUALTIES

Type of Person

Fatal

19.
Nonfatal

14. Other Train Miles

17. Number of Passengers Transported

NUMBER OF FRA FORMS ATTACHED

FRA Form Number

Worker on duty – railroad employee

6180.54

Railroad employees not on duty

6180.55a

Passengers on trains

6180.56

Nontrespassers/ on railroad property

6180.57

Trespassers

6180.81

Number Attached

Worker on duty - contractor
Contractor - other
Worker on duty - volunteer
Volunteer - other
Nontrespassers/ off railroad property
Grand total
20. Remarks Section. Please describe operational, environmental, or other circumstances that account for unusual fluctuations in train miles operated, employee hours, or
passenger counts.

NOTE: This report is part of the reporting railroad's accident report pursuant to the accident reports statute and, as such shall not "be admitted as evidence
or used for any purpose in any suit or action for damages growing out of any matter mentioned in said report. . . ." 49 U.S.C. 20903.
See 49 C.F.R. 225.7 (b).
This collection of information is mandatory under 49 CFR 225, and is used by FRA to monitor national rail safety. Public reporting burden is estimated to average XX minutes
per response, including the time for reviewing instructions, searching existing databases, gathering and maintaining the data needed, and completing and reviewing the
collection of information. The information collected is a matter of public record, and no confidentiality is promised to any respondent. Please note that an agency may not
conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number
for this collection is 2130-0500.

FORM FRA F 6180.55 (Rev. 06/10)

This report is required by law (49 USC 20901). Failure to report can result in the imposition of civil penalties.

OMB approval expires 02/28/2011

DRAFT 03/11/10