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NON-EMPLOYEE PERSONAL INJURY DATA COLLECTION <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 DF RESPONSIBILITY DR LIABILITY. <br /> I.Accident City/St: 2.Date: Time: <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 /> B.Name(last,first,mi): <br /> 7.Address: City: St: Zip: <br /> 8.Date of Birth: and/or Age: Gender: <br /> (if available) <br /> Shone Number: Employer: <br /> 9.Injury: ID.Body Part: <br /> (i.e.,Laceration,etc.) (i.e.,Hand,etc.) <br /> II.Description of Accident(To include location,action,result,etc.): <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 /> 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 <br />