FRA F 6180.150 Highway User Injury Inquiry Form

HIGHWAY USER INJURY INQUIRY FORM

DEPARTMENT OF TRANSPORTATION

OMB No. 2130-0500

Federal Railroad Administration (FRA)
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

2b. Alphabetic Code

2a. Name of Railroad

PM

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)
9b. First Name
9a. Highway User’s Last Name

9c. Middle Initial

11. Highway User's Telephone (Primary)

13. Highway User's E-mail Address

12. Highway User's Telephone (Secondary)

10. Highway User 's Age

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.

17b. Highway User’s Representative’s
Name (if applicable):

17a. Name of Person Completing Part II
Check Appropriate Box:
Highway User
Highway User's Representative

18. Signature

19. Date

Telephone Number:
Relationship:

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

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

HIGHWAY USER INJURY INQUIRY FORM
(Continued)
Identifying Information (from first page) :
Date of Accident/Incident (mm/dd/yyyy)
Highway User’s Last Name

Narrative Description - Continued

Railroad Accident/Incident Number
First Name

Middle Initial

(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.)

Public reporting burden is estimated to average 50 minutes per response for railroads for their part of this form and 45
minutes for highway users or their representatives for their part of this form. This includes the time for reviewing instructions,
searching existing databases, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Responses by the railroad are mandatory and responses by highway users or their representatives to this
collection of information are voluntary. 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.