FRA F 6180.73 Accident Information Required For Post-Accident Toxicolo

OMB No. 2130-0526
ACCIDENT INFORMATION REQUIRED FOR
POST-ACCIDENT TOXICOLOGICAL TESTING (49 CFR PART 219)

U.S. Department
of Transportation

NOTE: This form must be completed by the Railroad Representative present at the collection facility.

Federal Railroad
Administration

Public reporting burden for this information collection is estimated to average 10 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 2130-0526. 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.

1. Name of Reporting Railroad

2. Name(s) of Other Railroads Involved in Accident

3. Date of Accident (month/day/year)

4. Time of Accident
:
Hr

5. Locations of Accident (City and State)

AM

PM

Min

6. Nearest Railroad Station

7. Event which Qualifies Accident for Mandatory Post-Accident Testing (one must be checked)
NOTE: All accident events (not incidents) must meet the railroad property damage reporting threshold.
MAJOR TRAIN ACCIDENT:

Fatality
$1,000,000 damage or more (to railroad property)
Release of hazardous material (and evacuation)
Release of hazardous material (and reportable injury from product)

IMPACT ACCIDENT:

Reportable injury
Damage of $150,000 or more (to railroad property)

PASSENGER TRAIN ACCIDENT:
TRAIN INCIDENT:

Reportable injury to any person in the accident
Fatality to on-duty railroad employee

8. Name and Address of Collection Facility

9. Telephone Number of Collection Facility
(

)

10. Employee(s) Whose Samples are Contained in this Shipping Box.
NOTE: A sample set identification number is pre-printed on FRA Form 6180.74 and differs for each person.
NAME OF EMPLOYEE

JOB TITLE
(engineer, conductor, etc.)

TRAIN DESIGNATION

11. Name of Medical Review Officer

12. Address of Medical Review Officer

13. Name of Railroad Representative

14. Address of Railroad Representative

Telephone: (

Telephone: (
15. Signature of Railroad Representative

16. Date (month/day/year)

SAMPLE SET
IDENTIFICATION NUMBER

)

)

17. Was a breath alcohol test conducted
pursuant to the above accident under
FRA Authority?

Yes
No

FORM FRA F 6180.73 (Rev. 10/94)

Expires 07/31/2015