Below is the text from a Burlington Northern & Santa Fe Employee Personal Injury/Occupational Illness Report.  For BNSF railroaders injured on the job the road to fair compensation begins here; filling out this form.  How you fill out this form can have a substantial impact on your FELA injury claim.

Below, in blue print, R. Edward Pfiester has indicated some suggested responses to certain sections of this form.   Study these suggestions carefully; they indicate areas where injured railroaders sometimes make critical errors when filling out this form.  Print this form out and keep it with you while working on the railroad.

REMEMBER: YOU MUST PROVE THE RAILROAD WAS LEGALLY NEGLIGENT
IN ORDER TO RECEIVE ADEQUATE COMPENSATION UNDER F.E.L.A. LAW

“ ‘Normal’ conditions are often not ‘Legal’ conditions”

BNSF

 EMPLOYEE PERSONAL INJURY/OCCUPATIONAL ILLNESS REPORT
Each employee incurring an injury or occupational illness on duty and/or on property must fill out this section and forward entire form to their supervisor.
NAME OF INJURED PERSON AGE DATE OF BIRTH SENIORITY DATE SOCIAL SECURITY NUMBER
ADDRESS OF INJURED PERSON (STREET, CITY, ZIP CODE) TELEPHONE NUMBER
  (        )
LOCATION OF INJURY (CITY AND STATE) MILE POST STATION NO. DATE OF INJURY TIME
      [  ] AM     [   ]  PM

If Occupational Illness (Repetitive trauma, carpal tunnel, hearing loss, etc.)

WHEN DID YOU FIRST NOTICE SYMPTOMS? WHEN WERE YOU FIRST TREATED?
TEMPERATURE (Degrees) VISIBILITY   _DAWN  _DUSK  _DAY  _DARK
(Check correct response)		 WEATHER    _CLEAR  _RAIN  _SLEET  _CLOUD _FOG  _SNOW
(Check correct response)
DESCRIBE FULLY HOW INJURY OR OCCUPATIONAL ILLNESS OCCURRED: I MAY NOT BE AWARE OF ALL THE FACTS, BUT... (BE BRIEF, TO-THE-POINT.  DON'T SPECULATE, DON'T STATE CONCLUSIONS, E.G.; "THERE WAS NOTHING WRONG.")
DESCRIBE INJURIES OR OCCUPATIONAL ILLNESS:  THE FULL EXTENT OF INJURIES ARE UNCERTAIN, BUT I BELIEVE... (USE "ETC.")
Was the accident caused by conduct of any person other than yourself?  [X] YES    [  ] NO     If yes, please describe: INJURED PERSON SHOULD ALWAYS SAY "YES"
Could you, by more care on your part, have prevented your injury?        [  ] YES    [X] NO      If yes, how?  UNLESS ABSOLUTELY POSITIVE, INJURED PERSON SHOULD ALWAYS SAY "NO"
TYPE OF MEDICAL ATTENTION ADMINISTERED (PRESCRIPTION, BRACE, SPLINT, ETC):
NAME OF ATTENDING PHYSICIAN:                                       ADDRESS:
NAME OF ATTENDING FACILITY:                                            ADDRESS:
IN INJURY OCCURRED WHILE WORKING WITH ON TRACK EQUIPMENT, LIST THE INITIALS AND NUMBERS:
DEFECTS INVOLVED:   [  ] NONE    [  ] MACHINERY     [  ] STRUCTURES    [  ] EQUIPMENT     [  ] OTHER DEFECTS
IF ANY DEFECTS INVOLVED, IDENTIFY AND DESCRIBE:  CHECK AND LIST EVERY POSSIBLE DEFECT.  USE "ETC"
Have you ever sustained an injury before?    [  ] yes    [   ] no    NOT RELEVANT TO ACCIDENT
IMPORTANT: List All Persons Who Witnessed the injury or Can Give Any Information About It:

NAME

OCCUPATION

ADDRESS (Show Street & City)
THE ABOVE IS A CORRECT STATEMENT

Signed __________________________  Date ________________  BNSF Employee Number _______________
ANSWER ALL QUESTIONS FULLY (Use Reverse Side If Necessary)
NOTE: IF EMPLOYEE IS UNABLE TO COMPLETE THIS FORM, SUPERVISOR MUST COMPLETE AND HAVE EMPLOYEE SIGN.

Contact the Pfiester Law firm for assistance: 1-800-344-3352
www.pfiesterlaw.com

 

(c) MCMXCIX  R. Edward Pfiester, Jr., Esq., A Law Corporation