Date _____________ Location of Unsafe Condition _____________________________
Time _____________ Mile Post Location ________ Train/Job No. _________________
Employee Making Report _____________________ Occupation ___________________
Unsafe Condition/Practice __________________________________________________
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Was an Immediate Report made, i.e. Train Dispatcher, Manager, etc. ________________
If so, who? ______________________________________________________________
Is Immediate Protection Needed _____ Was Protection Provided ___________________
If So, What ______________________________________________________________
Suggested Corrective Action ________________________________________________ ________________________________________________________________________
Report Submitted to Amtrak Manager _____ If so, who ________________ Date ______
Report Submitted to Amtrak Joint Labor/Management Safety Committee _____________ What Committee _______________________________________________ Date ______
Report Submitted to Home Road Office, i.e., CSX, NS, CR, etc. ____________________
If so, who, what office ____________________________________ Date ____________
Report Submitted to Division 14 Safety Task Force _____________ Date ____________
Report Submitted to BLE State Legislative Director _____________Date ____________ Name ___________________________________State ___________________________
Was Corrective Action Taken, If So When and by Whom _________________________
Please Describe Action Taken _______________________________________________
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