Below
is the text from a Union Pacific Report of Personal Injury or Illness.
For UP 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” |
Union Pacific Railroad
REPORT OF PERSONAL INJURY OR ILLNESS |
FORM
52032 (Rev. 1-87) Replaces 2611-R & 52002 |
| RULE 404. UNION PACIFIC RAILROAD
SAFETY, RADIO AND GENERAL RULES FOR ALL EMPLOYES PROVIDES: "All cases of personal
injury while on duty or on company property must be promptly reported to proper authority
on prescribed form. Personal injury occurring while off duty must be reported to the
proper authority as soon as possible and prescribed written form completed upon return to
service." |
INSTRUCTIONS:
Answer all questions in each applicable section in your own handwriting as soon as
possible after an accident/incident occurs if injured, either on or off duty or suffer a
work-related illness. (If unable to complete the report, necessary information must
be furnished the person doing so in the employe's behalf.) |
SECTION I -- IDENTIFICATION OF ILL/INJURED |
| (1)
NAME OF ILL/INJURED |
(2)
RESIDENCE PHONE |
(3) AGE |
(4) BIRTH
DATE |
| (5)
ADDRESS (Number, Street, City, State & Zip Code) |
| (6)
SOCIAL SECURITY NUMBER |
(7)
[ ] MALE
[ ]
FEMALE |
(8)
MARITAL STATUS
[ ] Single [ ] Married [ ] Divorced [ ]
Widow/Widower [ ] Legally Separated |
| (9)
OCCUPATION |
10) DEPARTMENT |
(11) DATE
ENTERED SERVICE |
| (12)
IMMEDIATE SUPERVISOR |
(13) TIME SHIFT OR TRIP BEGAN |
(14)
ASSIGNED REST DAYS |
SECTION II -- DETAILS OF ACCIDENT/INCIDENT |
| (1) DATE
OF ACCIDENT/INCIDENT |
(2) TIME
[ ] AM [ ] PM |
(3)
LOCATION (Street, Track, Building, etc.) (City or Town) (State) |
(4)
MILE POST [ ] MAIN
TRACK
DIVISION
[ ]
YARD |
(5) WAS
ILL/INJURED PARTY
[ ] ON
DUTY [ ] ON COMPANY PROPERTY
[ ] OFF DUTY [
] OFF COMPANY PROPERTY |
(6)
WEATHER
[ ] CLEAR [ ] RAIN
[ ] SLEET [ ] OTHER (Explain)
[ ] CLOUDY [ ] SNOW [ ] FOG
TEMPERATURE |
(7)
VISIBILITY
[ ] DAYLIGHT [
] DAWN [ ] ARTIFICIAL LIGHTING
[ ]
DARK [ ]
DUSK |
| (8) NAMES AND OCCUPATIONS OF OTHERS ON CREW |
|
| (9) SPECIFIC JOB OR ACTIVITY BEING PERFORMED AT TIME OF ACCIDENT/INCIDENT |
| (10)
HOW DID ACCIDENT/INCIDENT OCCUR? 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") |
|
| (11)
WHAT SPECIFICALLY CAUSED THE ACCIDENT/INCIDENT LIST EVERY ASPECT OF RAILROAD FAULT, INCLUDING ALL FAILURES OF
MANAGEMENT AND OTHER CRAFTS & CO-WORKERS POSSIBLY INVOLVED. USE "ETC." |
|
| (12)
DID EQUIPMENT, TOOLS CAUSE OR CONTRIBUTE TO THE CAUSE OF THE ACCIDENT? [ ] Yes
[ ] No IF YES, PROVIDE COMPLETE DETAILS (Including equipment ID number)
LIST ALL POSSIBLE CAUSES. USE
"ETC." |
|
| (13)
DID WORKING CONDITIONS CAUSE OR CONTRIBUTE TO THE CAUSE OF THE ACCIDENT? [ ] Yes
[ ] No IF YES, PROVIDE COMPLETE DETAILS LIST ALL POSSIBLE CAUSES. USE "ETC." |
|
| (14)
DID OTHER PERSONS CAUSE OR CONTRIBUTE TO THE CAUSE OF THE ACCIDENT? [ ] Yes [
] No IF YES, PROVIDE COMPLETE DETAILS LIST ALL POSSIBLE CAUSES. IF YOU "PROTECT" YOUR FELLOW
EMPLOYEE, YOU POTENTIALLY HARM YOUR CLAIM (WHICH MIGHT BE CAREER-ENDING) |
|
| (15)
NAMES, OCCUPATIONS AND ADDRESSES OF ALL PERSONS WHO WITNESSED OR HAVE ANY KNOWLEDGE OF
ACCIDENT/INCIDENT LIST ALL
PERSONS AND ALL CRAFTS |
|
|
SECTION
III -- TRAIN OPERATION EQUIPMENT INVOLVED IN ACCIDENT/INCIDENT |
| (1) TRAIN
SYMBOL |
(2)
ENGINE NUMBER |
(3)
CONSIST (Loads, Empties, Tons) |
(4)
IDENTIFYING INITIALS & NUMBERS OF ENGINE, CABOOSE, CAR OR OTHER EQUIPMENT INVOLVED IN
ACCIDENT/INCIDENT |
(5)
EQUIPMENT WAS
[ ] STOPPED
TIME TABLE
[ ] MOVING -- SPEED______ DIRECTION |
(6) IF
ACCIDENT INVOLVED A CABOOSE, WAS IT
EQUIPPED WITH SEAT BELTS? [ ] Yes [ ] No
IF YES, WERE THEY IN USE? [ ] Yes
[ ] No |
(7)
WERE THERE ANY DEFECTS IN THE ENGINE, CABOOSE, OR CAR? [ ] Yes [ ]
No
LIST ALL POSSIBLE CAUSES. USE "ETC." |
| (8)
WERE THE BAD ORDER CONDITIONS MARKED? [ ] Yes [ ] No |
(9)
DID THIS ACCIDENT/INCIDENT RESULT FROM RIDING ON, BOARDING, OR ALIGHTING FROM, OR
BEING STRUCK OR RUN OVER BY MOVING ENGINE, CARS, CAR LADING OR OTHER EQUIPMENT?
[ ] Yes [ ] No |
| (10)
COMMENTS |
SECTION IV -- NATURE OF INJURY/ILLNESS AND TREATMENT |
| (1)
PARTS OF BODY AFFECTED |
(2) SIDE
OF BODY
[ ]
Right [ ] Left [ ] Both |
(3)
NATURE AND EXTENT OF INJURIES
THE FULL EXTENT OF INJURIES ARE UNCERTAIN, BUT I
BELIEVE. . . (USE "ETC.") |
(4)
WAS ILL/INJURED PARTY EXAMINED BY A DOCTOR? IF YES, DOCTOR'S NAME
AND ADDRESS
[ ] Yes [ ] No |
(5)
TREATMENT REQUIRED
[ ] NONE [ ]
FIRST AID [ ] TREATED & RELEASED [ ] X-RAYS
[ ] HOSPITALIZED [ ] OTHER (Explain) |
| (6) IF HOSPITALIZED, NAME AND ADDRESS OF HOSPITAL |
| (7)
WAS ILL/INJURED ABLE TO RETURN TO WORK ON NEXT WORK ASSIGNMENT? [ ] Yes
[ ] No |
(8)
COMMENTS |
|
|
Witness to Signature:_________________ |
I certify that the foregoing information is true and correct.
_______________________________
(signature of person completing report)
______________
(date) |
Contact the Pfiester Law firm for assistance:
1-800-344-3352
www.pfiesterlaw.com |
|