EMPLOYEE PERSONAL INJURY DATA COLLECTION. (If injuries are in connection with rail equipment accident/incident, highway rail grade crossing accident or automobile accident, ensure that appropriate information is obtained, forms completed and that data entry personnel are aware that injuries relate to that specific event.) Injured Person Type: Passenger on train (C) Non-employee (N) (i.e., emp of another railroad, or, non-BNSF emp involved in vehicle accident, including company vehicles) Contractor/safety sensitive (F) Contractor/non-safety sensitive (G) Volunteer/safety sensitive (H) Volunteer/other non-safety sensitive (I) Non-trespasser (D) - to include highway users involved in highway rail grade crossing accidents who did not go around or through gates Trespasser (E) - to include highway users involved in highway rail grade crossing accidents who went around or through gates Non-trespasser (J) - Off railroad property If train involved, Train ID: Transmit attached information to Accident/Incident Reporting Center by: Fax 0-000-000-0000 or by Phone 0-000-000-0000 or email to: Xxxxxxxx-Xxxxxxxxx.Xxxxxx@XXXX.xxx Officer Providing Information: (Name) (Employee No.) (Phone #) REPORT PREPARED TO COMPLY WITH FEDERAL ACCIDENT REPORTING REQUIREMENTS AND PROTECTED FROM DISCLOSURE PURSUANT TO 49 U.S.C. 20903 AND 83 U.S.C. 490 NON-EMPLOYEE PERSONAL INJURY DATA COLLECTION INFORMATION REQUIRED TO BE COLLECTED PURSUANT TO FEDERAL REGULATION. IT SHOULD BE USED FOR COMPLIANCE WITH FEDERAL REGULATIONS ONLY AND IT IS NOT INTENDED TO PRESUME ACCEPTANCE OF RESPONSIBILITY OR LIABILITY.
EMPLOYEE PERSONAL INJURY DATA COLLECTION. INFORMATION REQUIRED TO BE COLLECTED PURSUANT TO FEDERAL REGULATION. IT SHOULD BE USED FOR COMPLIANCE WITH FEDERAL REGULATIONS ONLY AND IS NOT INTENDED TO PRESUME ACCEPTANCE OF RESPONSIBILITY OR LIABILITY.
