AMTRAK
INJURY/ILLNESS REPORT (Revised 10/94) |
| 1.
DIVISION |
1a. RESCEN |
2.DATE
OF INCIDENT |
3.
MULTIPLE INJURY INCIDENT? |
|
4.
FRA CLASS OF INJURED PERSON (A,B,C,D,E,F) [ ]
WAS THIS A GRADE CROSSING ACCIDENT? [
]
WAS THIS A RAIL EQUIPMENT INCIDENT [EQUIPMENT OR
TRACK DAMAGE?] [ ] YES [ ] NO
4a. PRELIMINARY REPORTABILITY [ ]
YES [ ] NO 4b. PRELIMINARY
LOST TIME [ ] YES [ ] NO |
IDENTIFICATION
OF INJURED PERSON
5. Social Security Number _____l_____l__________
( Social Security Number Required for Amtrak Employee) |
| 6. Last
Name |
7. First
Name |
Middle
Initial: |
Home
Address:
(street, city, state, zip) |
| Sex |
Date of
Birth |
Married/Single |
Home Phone: |
| TIME
AND LOCATION OF INCIDENT |
| 8. TIME |
9.
Facility/Location/Place |
City: |
10.
State ______
Nearest Station:____________ |
| Mile Post |
Track No. |
Train No. |
Car No. |
Lead
Loco. No. |
Second
Loco. No. |
| Seat
No./Room No. |
Passenger
Origin: |
Passenger Destination: |
11. Time
Incident Reported to Supervisor: |
12. Date
Incident Reported to Supervisor: |
| 13.
Describe the activity that the injured/Ill person was engaged in: BE BRIEF, USE BROAD DESCRIPTION, SUCH AS "GOING DOWN STAIRS." |
| 14.
Describe how the injury/illness occurred: MENTION
DEFECTIVE CONDITION OR OTHER PERSON'S FAULT, EXAMPLE: "SLIPPED ON OILY STAIRS" |
| 15.
Name of the object or substance that directly caused the injury/illness: NAME ANY AND ALL POSSIBLE CAUSES, USE "ETC".
EXAMPLE: "OIL ON STAIRS, ETC." |
| 16.
Describe the injury/illness: "THE FULL
EXTENT OF INJURIES ARE UNCERTAIN, BUT I BELIEVE..." USE "ETC" |
| IDENTIFICATION OF IMMEDIATE SUPERVISOR OR PERSON IN CHARGE |
| 17.
Social Security Number |
18. Last
Name |
19. First Name |
Middle
Initial |
|
| Title |
Work
Phone ATS |
Bell |
|
_____________________
Supervisor's Signature |
20. Time 260 Completed |
21. Date |
Was
the Person Provided First Aid/Treatment? [ ] YES [
] NO
Name of Person Accompanying Injured Person to Medical
Facility ______________________ |
| INJURED EMPLOYEE INFORMATION |
| 22.
Occupation |
23. Dept. |
23a.
Tour of Duty |
23b. Crew
Base |
Func._____________
Work Order No._________ |
Gang No:
Hire Date:___/___/___ |
Extra
Board? (Y/N) |
24. Hours in to shift |
Day of
week
(MO, TU, WE,TH, FR, SA, SU) |
Rest Days
of Week:
____/____/____/____
Rule Violation Number: |
AMTRAK INJURY/ILLNESS REPORT
PERSONAL STATEMENT
(To be completed and signed by the injured person)
|
| Last Name |
First Name |
Middle
Initial |
Soc. Sec.
No. |
| Date of Accident |
Place of Accident |
| Amtrak may need to contact you within the next 72 hours. Please provide
a telephone number(s) where you can be reached. |
| Describe
Fully How Accident Occurred: "I
MAY NOT BE AWARE OF ALL THE FACTS, BUT..." (BE BRIEF, TO-THE-POINT. DON'T
SPECULATE, DON'T STATE CONCLUSIONS SUCH AS "THERE WAS NOTHING WRONG". DO NOT
SAY YOU WERE AT FAULT!!) |
| Describe
Cause of the Accident: LIST EVERY
ASPECT OF RAILROAD FAULT, INCLUDING: DEFECTIVE EQUIPMENT, DANGEROUS CONDITIONS, ALL
FAILURES OF MANAGEMENT AND OTHER CRAFTS & CO-WORKERS POSSIBLY INVOLVED. USE
"ETC." DO NOT SAY YOU WERE AT FAULT!! REMEMBER: IF THE ACCIDENT WAS
YOUR FAULT OR NOBODY'S FAULT, YOU WILL NOT RECEIVE ADEQUATE COMPENSATION -- POSSIBLY NO
COMPENSATION!! |
| Describe
Injury/Illness: THE FULL EXTENT OF INJURIES
ARE UNCERTAIN, BUT I BELIEVE... (USE "ETC.") |
Were
you provided first aid at the place of this accident? [
] YES [ ] NO
Were you taken to a medical facility for treatment? [
] YES [ ] NO
If yes, what was the name of the facility that you were taken to for
treatment: _______________________
Describe the treatment
provided:________________________________________________________
__________________________________________________________________________________ |
Witnesses:
(please print clearly)
Name
Department
Phone
Address
|
__________________________________________________
Signature of Injured Person
Date |