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RAILROAD INJURY AND ILLNESS SUMMARY DEPARTMENT OF TRANSPORTATION 1. Name of Reporting Railroad 5b. Day 5h. Drug/ Alcohol Test A D 5j. Physical Act 5i. Injury Illness Code OMB Approval No* 2130-0500 2. Alphabetic Code 5a* Accident/Injury Number SHEET OF Continuation Sheet FEDERAL RAILROAD ADMINISTRATION FRA 5c* Time of Day 3. Report Month 5d. County 5k. Location 4. Report Year 5e. State 5l* Event 5m* Result 5s. Latitude optional 5n* Cause 5o. Number of Days Away From Work 5p* Restricted 5f* Type Person/ Job Code 5q. Exposure to Hazmat 5g. Age 5r. Special Case 5t. Longitude optional 5u. Narrative Up to 250 Characters NOTE This report is part of the reporting railroad s accident report pursuant to the accident reports statute and as such shall not be admitted as evidence or used for any purpose in any suit or action for damages growing out of any matter mentioned in said report. Drug/ Alcohol Test A D 5j. Physical Act 5i. Injury Illness Code OMB Approval No* 2130-0500 2. Alphabetic Code 5a* Accident/Injury Number SHEET OF Continuation Sheet FEDERAL RAILROAD ADMINISTRATION FRA 5c* Time of Day 3. Report Month 5d. County 5k. Location 4. Report Year 5e. State 5l* Event 5m* Result 5s. Latitude optional 5n* Cause 5o. Report Month 5d. County 5k. Location 4. Report Year 5e. State 5l* Event 5m* Result 5s. Latitude optional 5n* Cause 5o. Number of Days Away From Work 5p* Restricted 5f* Type Person/ Job Code 5q. Exposure to Hazmat 5g. Age 5r. Number of Days Away From Work 5p* Restricted 5f* Type Person/ Job Code 5q. Exposure to Hazmat 5g. Age 5r. Special Case 5t. Longitude optional 5u. Narrative Up to 250 Characters NOTE This report is part of the reporting railroad s accident report pursuant to the accident reports statute and as such shall not be admitted as evidence or used for any purpose in any suit or action for damages growing out of any matter mentioned in said report. Drug/ Alcohol Test A D 5j. Physical Act 5i. Injury Illness Code OMB Approval No* 2130-0500 2. Alphabetic Code 5a* Accident/Injury Number SHEET OF Continuation Sheet FEDERAL RAILROAD ADMINISTRATION FRA 5c* Time of Day 3. Report Month 5d. County 5k. Location 4. Report Year 5e. State 5l* Event 5m* Result 5s. Latitude optional 5n* Cause 5o. Number of Days Away From Work 5p* Restricted 5f* Type Person/ Job Code 5q. Exposure to Hazmat 5g. Age 5r. Report Month 5d. County 5k. Location 4. Report Year 5e. State 5l* Event 5m* Result 5s. Latitude optional 5n* Cause 5o. Number of Days Away From Work 5p* Restricted 5f* Type Person/ Job Code 5q. Exposure to Hazmat 5g. Age 5r. Special Case 5t. Longitude optional 5u. Narrative Up to 250 Characters NOTE This report is part of the reporting railroad s accident report pursuant to the accident reports statute and as such shall not be admitted as evidence or used for any purpose in any suit or action for damages growing out of any matter mentioned in said report.

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