Form FRA F 6180.107 FRA F 6180.107 Alternate Record for Illness Claimed to Be Work Related

ALTERNATIVE RECORD FOR ILLNESSES CLAIMED TO BE WORK-RELATED
DEPARTMENT OF TRANSPORTATION

OMB No. 2130-0500

FEDERAL RAILROAD ADMINISTRATION (FRA)

1. Name of Reporting Railroad

2. Case/Incident Number

3. Employee’s Name (First, middle, last)

4. Employee’s Date of Birth
(mm/dd/yy)

5. Employee’s Gender
Male

6. Employee ID Number

7. Date Employee was Hired
(mm/dd/yy)

Female

8. Employee’s Home Address (include street address, city, State and ZIP code)

10. Name of Facility Where Railroad Employee Normally Reports to Work

9. Employee’s Home Telephone
Number (with area code)

11. Location, or Last Known Facility, Where Employee Reports to Work

12. Job Title of Railroad Employee

13. Department to Which Employee is Assigned

14. Date on Which Employee or Representative
Notified Company Personnel of Condition (mm/dd/yy)

15. Name of Railroad Official Notified

16. Title of Railroad Official Notified

17. Nature of Claimed Illness

18. Supporting Documentation
18.a. Custodian of Documents (Name, Title, and Address)

18.b. Location of Supporting Documentation

19. Narrative

20. Preparer’s Name

21. Preparer’s Title

22. Preparer’s Telephone
Number (with area code)

23. Date initially signed/completed

QUESTIONS AND ANSWERS
Q1. The only information provided to the railroad was the employee’s name and Employee ID Number. Further attempts to
complete the other data elements were rejected by the employee and/or his or her attorney. Does this meet FRA requirements?
A1. Yes. The railroad should continue to complete all the data elements when the information becomes available and should make
a good faith effort to obtain the information. However, the railroad is not expected to continue this effort past December 1 of the
year that follows the date on which the railroad first received a claim of the illness.
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
75 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. 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 6180.107 (Rev. 08/10)

OMB approved 7/30/2021, Approval expires 7/31/2023