Form FRA F 6180.119 FRA F 6180.119 Part 214 Railroad Workplace Safety Violation Report Form

OMB Expiration date: 11/30/2022

OMB No. 2130-0539

Part 214 Railroad Workplace Safety Violation Report Form

U.S. Department of Transportation
Federal Railroad Administration

REPORT GENERAL INFORMATION
1. Inspector Name:

2. Inspector's Viol. No.:

3. Annual F6180.96 No.:

4. Inspection Date:

5. Violation Date:

6. Violation Rpt. Date:

RAILROAD INFORMATION
7. RR/Co Initial:

8. Railroad/Company Name:

9. Division:

10. Subdivision:

11. Inspection Point:

ITEM(S) VIOLATED
12. Line Item: 13. Initials/Milepost: 14. Willful/ Non Willful: 15. Individual/Corporate:

18. Part No.:

19. Subpart Title:

20. Sect. No.:

16. Railroad/Contractor:

21. Section Title:

17. Method of Operation:

22. Paragraph:

23. Counts:

24. Text of Violated Paragraph:

NARRATIVE
25. Synopsis of Violation:

26. Seriousness/Reasons for Violation:

27. Other Items Found During Inspection (not recommended for violation):

28. Background/Special Circumstances:

29. Attachment List:

FRA INSPECTOR SIGNATURE
30. FRA Inspector Signature:

31. Date Signed:

RAILROAD/COMPANY REPRESENTATIVE
34. Title:

33. Name:

35. Accompanied FRA Inspector During Inspection:

32. FRA Inspector No. 2:

[ ] Yes

[ ] No

Public reporting burden for this information collection is estimated to average four (4) 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, no persons are required to respond to a collection of information unless it displays a currently valid OMB control number. The
valid OMB control number for this information collection is 2130-0539.

Form FRA F6180.119

9/04