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Form Fra F 6180.150 - Highway User Injury Inquiry Form - Department Of Transportation Page 2

HIGHWAY USER INJURY INQUIRY FORM

(Continued)

Identifying Information (from first page) :

Date of Accident/Incident (mm/dd/yyyy)

Railroad Accident/Incident Number

Highway User’s Last Name

First Name

Middle Initial

Narrative Description - Continued

(If additional space was needed in the Narrative Description boxes (15b. and 16b.), from the other side of this form, please

continue the narrative in this box.)

Public reporting burden is estimated to average 50 minutes per response for railroads for their part of this form and 45

minutes for highway users or their representatives for their part of this form. This includes the time for reviewing instructions,

searching existing databases, gathering and maintaining the data needed, and completing and reviewing the collection of

information. Responses by the railroad are mandatory and responses by highway users or their representatives to this

collection of information are voluntary. 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 6180.150 - Highway User Injury Inquiry Form - Department Of Transportation Page 2