FRA F 6180.150 Highway User Injury Inquiry Form

Accident/Incident Reporting and Recordkeeping

FRA F 6180.150 (8-10)

Accident/Incident Reporting and Recordkeeping

OMB: 2130-0500

Document [doc]
Download: doc | pdf



HIGHWAY USER INJURY INQUIRY FORM

DEPARTMENT OF TRANSPORTATION

Federal Railroad Administration (FRA) OMB Approval No. 2130-0500

PART I – Highway Rail-Grade Crossing Accident/Incident (To be completed by reporting railroad)

1a. Date of Accident/Incident (mm/dd/yyyy)


1b. Time of Accident/Incident AM PM

2a. Name of Railroad

2b. Alphabetic Code

3. Railroad Accident/Incident Number

4. U.S. DOT Grade Crossing Identification Number


5. Highway Name or Number



6. City (if in a city)

7. County

8. State Abbr.

PART II - Highway User Statement (To be completed by highway user or highway user's representative)

9a. Highway User’s Last Name


9b. First Name

9c. Middle Initial

10. Highway User 's Age

11. Highway User's Telephone (Primary)


12. Highway User's Telephone (Secondary)


13. Highway User's E-mail Address



14. Highway User's Mailing Address




15a. Did you suffer an injury, or injuries, as a result of the highway-rail grade accident/incident described above? Yes No

15b. Narrative Description: If you answered "Yes" to 15a., please describe the nature and severity of your injury, or injuries, the event(s) that caused the injury, or

injuries, and any other relevant information. You may continue the Narrative Description on back of form.






16a. As a result of your injury, or injuries, caused by the highway rail-grade crossing accident/incident, did you (please check all that apply and complete the Narrative

Description in 16b.):


(i) Receive medical treatment beyond first aid (i.e. prescription medication or stitches)

(ii) Lose consciousness

(iii) Suffer a fractured or cracked bone, or a punctured eardrum diagnosed by a physician or other licensed health care provider

(iv) Receive transportation from the highway rail-grade crossing accident/incident to a medical facility via emergency medical transportation (EMT) (i.e. ambulance)


16b. Narrative Description: (1) Describe any medical treatment received as a result of the accident; (2) Provide additional information about the boxes checked in

16a. above; and (3) Provide other related information. You may continue the Narrative Description on back of form.










17a. Name of Person Completing Part II

Check Appropriate Box:


Highway User

Highway User's Representative

17b. Highway User’s Representative’s

Name (if applicable):


Telephone Number:



Relationship:



18. Signature



19. Date

Note: Railroads are required to send this form under 49 CFR 225.

FORM FRA F 6180.150 (Rev. 08/10) NOTE THAT RAILROAD MUST REPORT ALL REPORTABLE CASUALTIES ON FORM FRA F 6180.55a

DRAFT

OMB approval expires 02/28/2011


HIGHWAY USER INJURY INQUIRY FORM

(Continued)

Identifying Information (from first page) :

Date of Accident/Incident (mm/dd/yyyy)


Railroad Accident/Incident Number

Highway User’s Last Name


First Name

Middle Initial


Narrative Description - Continued (If additional space was needed in the Narrative Description boxes (15b. and 16b.), from the other side of this form, please

continue the narrative in this box.)








































OMB Paperwork Reduction Statement (Forms)


Public reporting burden for this information collection is estimated to average 95 minutes per response - 50 minutes for railroads to complete their portion of the form and 45 minutes for highway users to complete their portion of the form. This estimate includes 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 2130-0500. 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, 1200 New Jersey Ave., S.E., Washington D.C. 20590.



File Typeapplication/msword
File Titledocument
AuthorVicki Hoffman
Last Modified ByUSDOT User
File Modified2010-08-11
File Created2010-08-11

© 2024 OMB.report | Privacy Policy