KCS Form 68-D

Personal Injury Form Guide

1) thru 22)

Complete with appropriate responses.

23) WHAT JOB OR ACTIVITY WAS BEING PERFORMED AT TIME OF INJURY:

Lining bad order switch.

24) DESCRIBE INJURY/ILLNESS AND ALL BODY PARTS AFFECTED:

List all body parts injured, no matter how minor it seems at the moment.

25) HOW DID INJURY OCCUR? (Include a sequence of events leading up to injury) Use back if necessary

While lining switch, switch hung up.

26) thru 35)

Complete with appropriate responses.

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