Schedule A

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 ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  .. . Railway

Report to the Board of Railway Commissioners for Canada as required by Section 292 of the Railway Act and General Order of the Board No. 244.

1.	Date and hour of accident
2.	Train.	Conductor.	Engine.
		Engineer.
3.	Province
4.	Place of accident State if in city, town, village, or township. If in city, town, or village, give name of Street; if no name, say how many crossings from station specifying direction. If in township, give distance in miles and fraction of mile from nearest station, specifying direction, also give distance of nearest mile post of Subdivision and any other information of an identifying character.
5.	(a) Particulars of accident. (b) Name of persons injured or killed and addresses.
6.	Was crossing protected at time of accident and if so in what manner?
7.	Time and date, speed limitation of ten miles an hour established or watchman put on as required by sec. 275 (sub-sec. 4) and General Order No. 77.
8.	If any previous accident at same place subsequent to 1900, give date, if more than one accident give date of last one only.
9.	Remarks covering any other information that the Company thinks should be submitted not covered by the foregoing details.
I certify that from inquiries made by me, or my knowledge, the foregoing return is-correct.
N.B.—Use only one form for each accident, attaching plain extension sheets if insufficient space here.		Signature  ..  ..  ..  ..  ..  ..  .. .
		Title  ..  ..  ..  ..  ..  ..  .. .

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