225.21--Alternative record for illnesses claimed to be work related--Form FRA F 6180.107

Accident/Incident Reporting and Recordkeeping

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2130-0500 can be found here:

Documents and Forms

Document Name Document Type
Form FRA F 6180.107 225.21--Alternative record for illnesses claimed to be work related--Form FRA F 6180.107 Form and Instruction
FRA F 6180.107 Alternate Record for Illness Claimed to Be Work Related FRA F 6180.107.pdf railroads.dot.gov/forms-guides-publications/forms/current-forms Form and Instruction

Information Collection (IC) Details

IC Title:	225.21--Alternative record for illnesses claimed to be work related--Form FRA F 6180.107	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 49 CFR 225

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FRA F 6180.107	Alternate Record for Illness Claimed to Be Work Related	FRA F 6180.107.pdf	https://railroads.dot.gov/forms-guides-publications/forms/current-forms	Yes	Yes	Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 765	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	188	188
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.