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 a copy to your Legislative Representative, and retain a copy for your records.

Employee Name: ____________________________________ Date of Report: ________________

Location of Unsafe Condition/Defect: _________________________________________________
(Track Number, Mile Post, Street Address)

Describe Unsafe Condition/Defect: ___________________________________________________

_______________________________________________________________________________

	Company Representative: _____________________________	Date:____________
	Legislative Representative: ____________________________	Date:____________
	Employee

(Check Mark Indicates Copy Sent)