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Contract Number: BF-20583561 <br /> <br /> <br /> <br />NON-EMPLOYEE PERSONAL INJURY DATA COLLECTION <br /> <br />Please complete this form and provide to the BNSF supervisor, who will input this information into the EHS Star system. For questions, <br />call (817) 352-1267 or email Safety.IncidentReporting@BNSF.com. <br /> <br />Accident City/State: Date: Time: <br />County: Temperature: Weather: <br />(if non-BNSF location) <br />Name (Last/First/MI): <br />Age: Gender (if available): <br />Company: <br />eRailsafe Badge Number: Expiration Date: <br />BNSF Contractor Badge Number: Expiration Date: <br />Injury: _ Body Part: <br /> (e.g., laceration) (e.g., hand) <br />Description of accident (including how accident occurred, potential cause, etc.): <br /> <br /> <br />Work activity in progress at time of accident: <br />Tools, machinery, or hazardous materials involved in accident: <br /> <br />Treatment: <br /> First Aid Only <br /> Required Medical Treatment <br /> Other Medical Treatment: <br />Dr. Name: Date: <br />Dr. Street Address: City: State: Zip: <br />Hospital Name: <br />Hospital Street Address: City: State: Zip: <br />Diagnosis: <br /> <br />THIS REPORT IS PART OF BNSF’S ACCIDENT REPORT PURSUANT TO THE ACCIDENT REPORTS STATUTE AND, AS SUCH SHALL NOT “BE <br />ADMITTED AS EVIDENCE OR USED FOR ANY PURPOSE IN ANY SUIT OR ACTION FOR DAMAGES GROWING OUT OF ANY MATTER <br />MENTIONED IN SAID REPORT….” 49 U.S.C. § 20903. See 49 C.F.R. § 225.7(b). <br /> <br />