FRA F 6180.98 Railroad Employee Injury and/or Illness Record

RAILROAD EMPLOYEE INJURY AND/OR ILLNESS RECORD

DEPARTMENT OF TRANSPORTATION

OMB No. 2130-0500

FEDERAL RAILROAD ADMINISTRATION (FRA)

1. Railroad

2. Case/Incident Number

EMPLOYEE INFORMATION
4. Date of Birth

3. Last Name, First Name, Middle Initial

HOME
ADDRESS:

8. Street Address (include Apt. No.)

ESTABLISHMENT/
FACILITY WHERE
EMPLOYEE
NORMALLY REPORTS:

5. Sex (M/F)

6. Employee ID Number

10. State

9. City

11. ZIP

7. Date Hired

12. Home Telephone No.
(include area code)

13. Name of Facility
15. City

14. Street Address

18. Job Title

16. State

17. ZIP

19. Department Assigned To

ACTIVITY/INCIDENT/EXPOSURE DESCRIPTION
LOCATION WHERE
ACCIDENT/
INCIDENT/
EXPOSURE
OCCURRED:
25. Is this on your premises?
Yes

COMPANY
NOTIFICATION:

20. Specific Site

21. City

22. County

26. Date of Occurrence

23. State

27. Time Shift Began AM

28. Time of Occurrence AM

PM

PM

No
30. Date that Employee Notified
Company Personnel of Condition

31. Time that Employee Notified
AM
Company Personnel of Condition
PM

24. ZIP

29. Was person on duty?
Yes

No

32. Person Notified

33. Describe the general activity this person was engaged in prior to injury/illness.

34. Describe all factors associated with this case that are pertinent to an understanding of how it occurred. Include a discussion of the sequence of
events leading up to it, and the tools, machinery, processes, material, environmental conditions, etc., involved.

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).

FORM FRA F 6180.98 (Rev. 08/10)

OMB approval expires 05/31/2017

INJURY/CONDITION INFORMATION
35. Describe in detail the injury/condition that this person sustained. Include a discussion of the body parts affected. If this is a recurrence, list date
of last occurrence.

36. Identify all persons and organizations used to evaluate and/or treat condition. (Include facility, provider, and address)

37. Describe all procedures, medications, therapy, etc., used/recommended for the treatment of condition:

38. Check any of the following consequences resulting from this injury/condition:
Hospitalization for treatment as an
inpatient.

Death. Date of: _______________
Restriction of work. Reportable days of restricted activity: ____________ as of: ____________

Multiple treatments or therapy sessions.

Occupational illness. Date of initial diagnosis:

Loss of consciousness.

Instructions to obtain prescription medication, or receipt of prescription medication.
Missed a day of work or next shift. Reportable days absent from work: ____________ as of: ____________
Significant injury/illness, one meeting specific case criteria, or a covered data case.
Medical treatment. This includes any medical care or treatment beyond “first aid” that is given, or should have been given, regardless of
who provided the treatment. “First Aid” treatment is limited to very simple procedures, e.g., application of a bandaid on minor scratches,
cuts, abrasions, etc.
Transfer to another job or termination of employment.
39. If any of the above consequences occurred, the injury/condition is almost always reportable to FRA on Form FRA F 6180.55a. If you believe this case
does not meet the reporting criteria, you must give a brief explanation below of the basis for this decision. Was the case reported?
Yes
No

40. Has this employee been provided an opportunity to review his or her file?
41. Preparer’s Name

42. Preparer’s Title

Yes

No
43. Telephone Number

44. Date initially
signed/completed

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 1 hour 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.