UNSAFE CONDITION

UNSAFE CONDITION / DEFECTIVE EQUIPMENT REPORT

Employee: Complete this form concerning any unsafe condition / defective equipment that you may find while at work.

Report the problem to your supervisor on duty with the original copy. Then give the yellow copy to your Legislative Representative.

Employee Name:__________________________

Date of Report: ___________________________

Location of Unsafe Condition / Defect: ___________________________

(Track Number, Mile Post, Street Address)

Describe Unsafe Condition / Defect:

_____________________________________________________________________________

Original Company Representative:_____________________ Date: ___________

Yellow Copy Legislative Representative: _____________________ Date: ___________

Pink Copy Employee: __________________________