FRA F 6180.111 Track Violation Report Form

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

Track Violation Report Form

1. Inspector Name:

2. Inspector's Viol. No.:

3. Annual F6180.96 No.:

4. Inspection Date:

5. Violation Date:

6. Violation Rpt. Date:

RAILROAD INFORMATION
7. RR/Co Initial:

8. Railroad/Company Name:

9. Division:

10. Subdivision:

11. Inspection Point:

ITEM(S) VIOLATED
12. Track Type: 13. Track Name/No.:

14. Initials/Milepost:

15. Speed: 16. Track Class:

17. MGT:

18. HazMat:

19. Method of Operation:

[ ] Yes [ ] No
20. Line Item: 21. Part No.:

23. Sect. No.: 24. Section Title:

22. Part Title:

25. Paragraph/
Code:

26. Counts:

27. Text of Violated Paragraphs:

NARRATIVE
28. Synopsis of Violation:

29. Geographic Condition/Description:

30. Seriousness/Reasons for Violation:

31. Prior or Constructive Knowledge:

32. Other Items Found During Inspection (not recommended for violation):

33. Background/Special Circumstances:

34. Attachment List:

FRA INSPECTOR SIGNATURE
35. FRA Inspector Signature:

36. Date Signed:

37. FRA Inspector No. 2:

RAILROAD/COMPANY REPRESENTATIVE
38. Name:

39. Title:

40. Accompanied FRA Inspector During Inspection:
[ ] Yes

[ ] No

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 F6180.111

(9/04)

OMB approval expires 11/30/2006