BNSF Form SAF51662 12/11/2003

Personal Injury Form Guide

DESCRIBE FULLY HOW INJURY OR OCCUPATIONAL ILLNESS OCCURRED (attach additional pages if necessary):

Switch hung up while lining. (less is more here, just indicate what negligence caused the injury)

WAS THE ACCIDENT CAUSED BY THE CONDUCT OF ANOTHER PERSON? YES / NO IF YES, PLEASE DESCRIBE:

Yes, those responsible for maintaing the switch.

COULD YOU, BY MORE CARE ON YOUR PART, HAVE PREVENTED YOUR INJURY? YES / NO IF YES, HOW?

No

WAS THERE ANYTHING WRONG WITH THE EQUIPMENT, WORK PROCEDURES, OR WORK AREA WHICH LED TO THIS ACCIDENT? YES / NO

IF YES, PLEASE DESCRIBE:

Yes, bad order switch.

Sign, date and make sure you get a copy of the completed form.