FRA F6180.75 FRA Collection of Post-Mortem Toxicology Samples Require

OMB No. 2130-0526

FEDERAL RAILROAD ADMINISTRATION
COLLECTION OF POST-MORTEM TOXICOLOGY SAMPLES
REQUIRED BY 49 CFR PART 219

Public reporting burden for this information collection is estimated to average 20 minutes/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 2130-0526. All responses
to this collection of information are voluntary. 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., SE, Washington DC 20590.

Samples taken will be tested as part of the Federal Railroad Administration’s investigation to
determine cause of the rail accident. Samples being harvested in accordance with Federal law
and consent is not required (49 CFR Part 219.11 (f)).

Railroad:

Date of Accident:

Deceased’s Name (Print):

Date and Time Samples Taken:

Specimen ID:

I certify that I collected the samples identified below under proper Custody and Control procedures and with
accepted scientific standards of practice.
Print Name

Signature

Collection Instructions Are Included in the Fatality Box
Please Harvest all of the Samples Below If Possible (In Order of Priority to FRA):
Whole Blood
(20 mL)
Yes
No
Source of Blood:
Urine
(60 mL)
Yes
No
Vitreous
(All Available)
Yes
No
Liver
(50 gr)
Yes
No
Brain
(50 gr)
Yes
No
Kidney
(50 gr)
Yes
No
Optional Samples (If Two or More of the Above Samples are Not Available):
Bile, Spleen, Lung
Yes
Specify:
Other Samples of Interest if Vitreous or Urine Not Available:
Spinal Fluid (All Available)

Yes

Gastric Contents (60 mL)

Samples Released to (Courier Service):
Were there any signs of decomposition?
If yes, please explain:

Yes

Received at FRA Laboratory by:
Yes

No

Additional Remarks:

FRA6180.75 (9/14)

Copy 1 - Federal Railroad Administration
Distribution Instructions are different on each part.

Expires: 08/31/2018