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<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 />1. Accident City/St: 2. Date: Time: <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> County: 3. Temperature: 4. Weather: <br /> (if non BNSF location) <br /> Mile Post / Line Segment: <br /> 5. Driver’s License No (and state) or other ID: SSN (required): <br /> 6. Name (last, first, mi): <br /> 7. Address: City: St: Zip: <br /> 8. Date of Birth: and/or Age: Gender: <br /> (if available) <br /> Phone Number: Employer: <br />Zip: <br /> <br /> <br /> 9. Injury: 10. Body Part: <br /> (i.e., Laceration, etc.) (i.e., Hand, etc.) <br /> 11. Description of Accident (To include location, action, result, etc.): <br /> <br /> <br /> <br /> 12. Treatment: <br /> First Aid Only <br /> Required Medical Treatment <br /> Other Medical Treatment <br /> 13. Dr. Name: Date: <br /> 14. Dr. Address: <br /> Street: City: St: Zip: <br /> 15. Hospital Name: <br /> 16. Hospital Address: <br /> Street: City: St: Zip: <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