Form Fra F 6180 98 PDF Details

In the bustling world of the railroad industry, ensuring the safety and well-being of employees is paramount. This is where the Department of Transportation's Federal Railroad Administration (FRA) plays a crucial role, especially with the implementation of the FRA F 6180 98 form, officially known as the Railroad Employee Injury and/or Illness Record. This document is an essential tool for the meticulous reporting and tracking of any injuries or illnesses that occur among railroad workers. It meticulously gathers detailed information about the employee, including personal details, employment information, and the specifics of the incident, such as where, when, and how it happened. Additionally, it dives into the nature of the injury or illness, the treatment administered, and any significant consequences of the incident, such as death, hospitalization, or missed workdays. This form plays a critical role in maintaining safety standards within the railroad industry by facilitating a thorough investigation of accidents and exposures to hazardous conditions, with the ultimate goal of preventing future incidents. Moreover, it emphasizes the importance of transparency and accountability, requiring that the collected information be reported and made available as a matter of public record. By ensuring that every incident is properly documented and reported, the FRA F 6180 98 form contributes significantly to ongoing efforts to enhance rail safety across the nation.

QuestionAnswer
Form NameForm Fra F 6180 98
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfra form 6180 97 fillable, fra f 98 download, fra f 6180 98, fra f 6180 56

Form Preview Example

RAILROAD EMPLOYEE INJURY AND/OR ILLNESS RECORD

DEPARTMENT OF TRANSPORTATION

FEDERAL RAILROAD ADMINISTRATION (FRA)

OMB No. 2130-0500

1. Railroad

2. Case/Incident Number

EMPLOYEE INFORMATION

 

3. Last Name, First Name, Middle Initial

4.

Date of Birth

5. Sex (M/F)

 

6.

Employee ID Number

7. Date Hired

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME

8. Street Address (include Apt. No.)

9.

City

 

10.

State

11. ZIP

12. Home Telephone No.

 

 

 

 

 

 

 

 

 

(include area code)

 

ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ESTABLISHMENT/ FACILITY WHERE EMPLOYEE NORMALLY REPORTS:

13. Name of Facility

14. Street Address

15. City

16. State

17. ZIP

 

 

 

 

18. Job Title

19. Department Assigned To

 

 

ACTIVITY/INCIDENT/EXPOSURE DESCRIPTION

LOCATION WHERE

 

20.

Specific Site

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCIDENT/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INCIDENT/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EXPOSURE

 

 

 

21.

City

 

22. County

 

 

 

 

 

23.

State

24.

ZIP

OCCURRED:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25. Is this on your premises?

 

26. Date of Occurrence

27. Time Shift Began AM

 

28. Time of Occurrence AM

 

 

29. Was person on duty?

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

PM

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPANY

 

 

 

30.

Date that Employee Notified

31. Time that Employee Notified

AM

 

32. Person Notified

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTIFICATION:

 

 

 

 

 

Company Personnel of Condition

 

Company Personnel of Condition

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33. Describe the general activity this person was engaged in prior to injury/illness.

34.Describe all factors associated with this case that are pertinent to an understanding of how it occurred. Include a discussion of the sequence of events leading up to it, and the tools, machinery, processes, material, environmental conditions, etc., involved.

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).

FORM FRA F 6180.98 (Rev. 08/10)

OMB approval expires 05/31/2017

INJURY/CONDITION INFORMATION

35.Describe in detail the injury/condition that this person sustained. Include a discussion of the body parts affected. If this is a recurrence, list date of last occurrence.

36. Identify all persons and organizations used to evaluate and/or treat condition. (Include facility, provider, and address)

37. Describe all procedures, medications, therapy, etc., used/recommended for the treatment of condition:

38. Check any of the following consequences resulting from this injury/condition:

Death. Date of: _______________

Restriction of work. Reportable days of restricted activity: ____________ as of: ____________

Occupational illness. Date of initial diagnosis:

Instructions to obtain prescription medication, or receipt of prescription medication.

Hospitalization for treatment as an inpatient.

Multiple treatments or therapy sessions.

Loss of consciousness.

Missed a day of work or next shift. Reportable days absent from work: ____________ as of: ____________

Significant injury/illness, one meeting specific case criteria, or a covered data case.

Medical treatment. This includes any medical care or treatment beyond “first aid” that is given, or should have been given, regardless of who provided the treatment. “First Aid” treatment is limited to very simple procedures, e.g., application of a bandaid on minor scratches, cuts, abrasions, etc.

Transfer to another job or termination of employment.

39. If any of the above consequences occurred, the injury/condition is almost always reportable to FRA on Form FRA F 6180.55a. If you believe this case

does not meet the reporting criteria, you must give a brief explanation below of the basis for this decision. Was the case reported?

Yes

 

No

 

40.

Has this employee been provided an opportunity to review his or her file?

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

41.

Preparer’s Name

42. Preparer’s Title

 

 

 

43. Telephone Number

44. Date initially

 

 

 

 

 

 

 

 

 

signed/completed

 

 

 

 

 

 

 

 

 

 

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 1 hour 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.