FRA F 6180.55a Railroad Injury and Illness Summary (Continuation Sheet)

RAILROAD INJURY AND ILLNESS SUMMARY

DEPARTMENT OF TRANSPORTATION

2. Alphabetic Code

1. Name of Reporting Railroad

5a.
Accident/Injury Number

5h.
Drug/
Alcohol Test
A
D

5i.
Injury
Illness
Code

5b.
Day

5j.
Physical
Act

SHEET ___ OF ___

OMB No. 2130-0500

(Continuation Sheet)

FEDERAL RAILROAD ADMINISTRATION (FRA)

5c.
Time
of Day

5k.
Location

5d.
County

5l.
Event

3. Report Month

5e.
State

5m.
Tools

5s. Latitude

5n.
Cause

5o.
Number of
Days Away
From Work

5p.
Number of
Days
Restricted

4. Report Year

5f.
Type
Person/
Job Code

5q.
Exposure to
Hazmat

5g.
Age

5r.
Special Case
Codes

5t. Longitude

5u. Narrative (Up to 250 Characters)

5a.
Accident/Injury Number

5h.
Drug/
Alcohol Test
A
D

5i.
Injury
Illness
Code

5b.
Day

5j.
Physical
Act

5c.
Time
of Day

5k.
Location

5d.
County

5l.
Event

5e.
State

5m.
Tools

5s. Latitude

5n.
Cause

5o.
Number of
Days Away
From Work

5p.
Number of
Days
Restricted

5f.
Type
Person/
Job Code

5q.
Exposure to
Hazmat

5g.
Age

5r.
Special Case
Codes

5t. Longitude

5u. Narrative (Up to 250 Characters)

5a.
Accident/Injury Number

5h.
Drug/
Alcohol Test
A
D

5i.
Injury
Illness
Code

5b.
Day

5j.
Physical
Act

5c.
Time
of Day

5k.
Location

5s. Latitude

5d.
County

5l.
Event

5e.
State

5m.
Tools

5n.
Cause

5o.
Number of
Days Away
From Work

5p.
Number of
Days
Restricted

5f.
Type
Person/
Job Code

5q.
Exposure to
Hazmat

5g.
Age

5r.
Special Case
Codes

5t. Longitude

5u. Narrative (Up to 250 Characters)

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).
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
20 minutes 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. In trespasser cases and in cases of suicide/attempted suicides, the estimated average time to complete this form is 50
minutes and 65 minutes, respectively. 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.

FORM FRA F 6180.55a (Rev. 08/10)

OMB approved 6/5/2018, Approval expires 6/30/2021