BLUEWATER MICHIGAN CHAPTER NRHS
CREW/PASSENGER ACCIDENT REPORT
DATE_____________
NAME OF PERSON COMPLETING THIS REPORT
(Printed)_________________________(Signature)______________________
DATE & TIME OF INJURY__________________________, ______
AM or PM.
ASSIGNED POSITION OR DUTY ON DAY OF
INCIDENT__________________
INJURED PASSENGER\MEMBER OF GENERAL PUBLIC\CREW NAME(S)
________________________________________________________________________________________________________________________________
NATURE OF INJURY (AS YOU CAN SEE OR BY INJURED PERSON'S
STATEMENT)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ADDRESS/PHONE NUMBER OF INJURED PERSON(S) __________________
________________________________________________________________________________________________________________________________
LOCATION OF ACCIDENT (EXAMPLE: CAR 857, ON THE TRACKS BESIDE
CAR 829, MEN'S RESTROOM CAR 832) ______________________________
________________________________________________________________________________________________________________________________
NAMES OF WITNESSES; ADDRESS & PHONE NUMBER:
________________
________________________________________________________________________________________________________________________________
WHO DID YOU REPORT ACCIDENT TO?
_____________________________
________________________________________________________________
DESCRIBE HOW THE ACCIDENT HAPPENED. USE BACK OF THE FORM, IF
NEEDED. _______________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________