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<br /> <br /> <br /> <br /> <br />NON-EMPLOYEE PERSONAL INJURY DATA COLLECTION <br /> <br />(If injuries are in connection with rail equipment accident/incident, highway rail grade crossing accident or automobile <br />accident, ensure that appropriate information is obtained, forms completed and that data entry personnel are aware that <br />injuries relate to that specific event.) <br /> <br /> <br />Injured Person Type: <br /> <br /> <br />Passenger on train (C) Non-employee (N) <br />(i.e., emp of another railroad, or, non-BNSF emp involved in vehicle accident, including <br />company vehicles) <br /> <br />Contractor/safety sensitive (F) Contractor/non-safety sensitive (G) <br /> <br />Volunteer/safety sensitive (H) Volunteer/other non-safety sensitive (I) <br /> <br />Non-trespasser (D) - to include highway users involved in highway rail grade crossing accidents who did not <br />go around or through gates <br />Trespasser (E) - to include highway users involved in highway rail grade crossing accidents who went <br />around or through gates <br />Non-trespasser (J) - Off railroad property <br />If train involved, Train ID: <br /> <br /> <br /> <br />Transmit attached information to Accident/Incident Reporting Center by: <br />Fax 1-817-352-7595 or by Phone 1-800-697-6736 or email to: Accident-Reporting.Center@BNSF.com <br /> <br /> <br />Officer Providing Information: <br /> <br /> (Name) (Employee No.) (Phone #) <br /> <br />REPORT PREPARED TO COMPLY WITH FEDERAL ACCIDENT REPORTING REQUIREMENTS AND PROTECTED FROM <br />DISCLOSURE PURSUANT TO 49 U.S.C. 20903 AND 83 U.S.C. 490