FRA F 6180.112 Signal & Train Control Violation Report Form

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

Signal & Train Control Violation Report Form
2. Violation of 49 CFR:

1. Subject:

Part

5. Railroad:

GSA Codes

City:

3. Viol. Rpt. No.:

4. F6180.96 Rpt. No. - Date:

Subrule

6. Name of Inspector(s):

Int:

7. Location:

Rule

ID No.:

8. Date of Violation:
Month

9. Time of Violation:
Day

Year

State:

10. Operation/Facility:

11. Division:

12. Track:

13. Locomotive Initials and Numbers:

14. Train #/Site:

NARRATIVE
15. Synopsis of Violation:

16. Rule Violation:

17. Date/Location of Inspection, Speed/Class of Track, System Inspected and Accompanying Personnel:

18. Description of Defective Condition:

19. Seriousness/Reason for Violation:

20. Corrective Action:

21. Inspector Recommendation:

22. Date Report Prepared:

23. Signature of Inspector(s):

24. Carrier Notification:
Name:
Title:
Date:
Time:

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 F6180.112

(9/04)

OMB approval expires 11/30/2006