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<br /> <br /> <br />NON-EMPLOYEE PERSONAL INJURY DATA COLLECTION <br /> <br />INFORMATION REQUIRED TO BE COLLECTED PURSUANT TO FEDERAL REGULATION. IT SHOULD BE USED FOR COMPLIANCE WITH FEDERAL REGULATIONS ONLY AND IT IS NOT <br />INTENDED TO PRESUME ACCEPTANCE OF RESPONSIBILITY OR LIABILITY. <br /> <br /> <br />1. Accident City/St: 2. Date: Time: <br /> <br /> <br />County: 3. Temperature: 4. Weather: <br /> <br /> (if non BNSF location) <br /> <br />Mile Post / Line Segment: <br /> <br />5. Driver’s License No (and state) or other ID: <br />SSN (required): <br /> <br />6. Name (last, first, mi): <br /> <br />7. Address: <br /> <br />City: <br /> <br />St: <br />Zip: <br /> <br />8. Date of Birth: <br /> <br />and/or Age: <br /> <br />Gender: <br />(if available) <br /> <br />Phone Number: Employer: <br /> <br /> <br />9. Injury: 10. Body Part: <br /> <br /> (i.e., Laceration, etc.) (i.e., Hand, etc.) <br /> <br />11. Description of Accident (To include location, action, result, etc.): <br /> <br /> <br /> <br /> <br /> <br /> <br />12. Treatment: <br /> <br />First Aid Only <br /> <br /> Required Medical Treatment <br /> <br /> Other Medical Treatment <br /> <br /> <br />13. Dr. Name: Date: <br /> <br /> <br />14. Dr. Address: <br />Street: City: St: Zip: <br /> <br /> <br />15. Hospital Name: <br /> <br /> <br />16. Hospital Address: <br />Street: City: St: Zip: <br /> <br /> <br />17. Diagnosis: <br /> <br /> <br />REPORT PREPARED TO COMPLY WITH FEDERAL ACCIDENT REPORTING REQUIREMENTS <br />AND PROTECTED FROM DISCLOSURE PURSUANT TO 49 U.S.C. 20903 AND 83 U.S.C. 490