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<br />NON-EMPLOYEE PERSONAL INJURY DATA COLLECTION <br /> <br />INFORMATION REQUIRED TO BE COLLECTED PURSUANT TO FEDERAL REGULATION. IT SHOULD <br />BE USED FOR COMPLIANCE WITH FEDERAL REGULATIONS ONLY AND IS NOT INTENDED TO <br />PRESUME ACCEPTANCE OF RESPONSIBILITY OR LIABILITY. <br /> <br />Time: <br />4. Weather <br /> <br />1. Accident City/St <br />County: <br />(if non-Railway location) <br /> <br />2. Date: <br />3. Temperature: <br /> <br />5. Social Security # <br /> <br />6. Name (last, first, mi) <br /> <br />7. Address: Street: <br /> <br />City: <br /> <br />St._ Zip: <br /> <br />8. Date of Birth: <br /> <br />and/or Age Gender: <br />(if available) <br /> <br />9. (a) Injury: <br />(Le. (a) Laceration (b) Hand) <br /> <br />(b) Body Part: <br /> <br />11. Description of Accident (To include location. action, result, etc.): <br /> <br />12. Treatment: <br />? First Aid Only <br />? Required Medical Treatment <br />? Other Medical Treatment <br /> <br />13. Dr. Name <br /> <br />30. Date: <br /> <br />14. Dr. Address: <br />Street: <br /> <br />City: <br /> <br />St: _ Zip: <br /> <br />15. Hospital Name: <br /> <br />16. Hospital Address: <br />Street: <br /> <br />City: <br /> <br />St: _ Zip: <br /> <br />17. Diagnosis: <br /> <br />FAX TO <br />RAILWAY AT (817) 352-7595 <br />AND COpy TO <br />RAILWAY ROADMASTERFAX <br /> <br />7 <br /> <br />Form 0102 Rev. 01120/05 <br /> <br />-185- <br />