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Form Fra F 6180.150 - Highway User Injury Inquiry Form - Department Of Transportation

HIGHWAY USER INJURY INQUIRY FORM

DEPARTMENT OF TRANSPORTATION

OMB No. 2130-0500

Federal Railroad Administration (FRA)

PART I – Highway Rail-Grade Crossing Accident/Incident (To be completed by reporting railroad)

1a. Date of Accident/Incident

(mm/dd/yyyy)

1b. Time of Accident/Incident

2a. Name of Railroad

2b. Alphabetic Code

3. Railroad Accident/Incident Number

4. U.S. DOT Grade Crossing Identification Number

5. Highway Name or Number

6. City (if in a city)

7. County

8. State Abbr.

PART II - Highway User Statement (To be completed by highway user or highway user's representative)

9a. Highway User’s Last Name

9b. First Name

9c. Middle Initial

10. Highway User 's Age

11. Highway User's Telephone (Primary)

12. Highway User's Telephone (Secondary)

13. Highway User's E-mail Address

14. Highway User's Mailing Address

15a. Did you suffer an injury, or injuries, as a result of the highway-rail grade accident/incident described above?

Yes

15b. Narrative Description: If you answered "Yes" to 15a., please describe the nature and severity of your injury, or injuries, the event(s) that caused the injury, or

injuries, and any other relevant information. You may continue the Narrative Description on back of form.

16a. As a result of your injury, or injuries, caused by the highway rail-grade crossing accident/incident, did you (please check all that apply and complete the Narrative

Description in 16b.):

(i) Receive medical treatment beyond first aid (i.e. prescription medication or stitches)

(ii) Lose consciousness

(iii) Suffer a fractured or cracked bone, or a punctured eardrum diagnosed by a physician or other licensed health care provider

(iv) Receive transportation from the highway rail-grade crossing accident/incident to a medical facility via emergency medical transportation (EMT) (i.e. ambulance)

16b. Narrative Description: (1) Describe any medical treatment received as a result of the accident; (2) Provide additional information about the boxes checked in

16a. above; and (3) Provide other related information. You may continue the Narrative Description on back of form.

17a. Name of Person Completing Part II

17b. Highway User’s Representative’s

18. Signature

19. Date

Name (if applicable):

Check Appropriate Box:

Telephone Number:

Highway User

Highway User's Representative

Relationship:

Note: Railroads are required to send this form under 49 CFR 225.