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NON -EMPLOYEE PERSONAL INJURY DATA COLLECTION <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 />I. Accident City/St <br />Colony: <br />(if nun -Railway location) <br />5. Social Security 0 <br />6. Name (last, first, mi) <br />7. Address: Street: <br />8. Date of Binh: <br />2. Date: _ <br />3. Temperature: <br />City: <br />and/or Age Gender: <br />(i f avai lablc) <br />9. (a) Injury: (b) Body Pan: <br />(i.e. (a) Laceration (b) Hand) <br />11. Description of Accident (To include location, action, result, ctc.): <br />12. Treatment: <br />? First Aid Only <br />? Required Medical Treatment <br />? Other Medical Treatment <br />13. Dr. Name <br />14. Dr. Address: <br />Street: <br />I5. Ilospital Name: <br />16. I lospital Address: <br />Street: <br />17. Diagnosis: <br />FAX TO <br />RAI LWAY AT (817) 352-7595 <br />AND COPY TO <br />RAILWAY ROADMASFER FAX <br />City: <br />City: <br />30. Date: <br />Time: <br />4. Weather <br />St. Zip: <br />St: Zip: <br />St:. zip: <br />Capital projects Comntttler Rail 7 IFB No. RTA/CP 21-06 <br />Everett Station Phase 2 EXHIBIT "C <br />CONTRACTOR REQUIRMENTS Form 0102 Rev. 02/04 <br />