NORFOLK SOUTHERN EMPLOYEES

UNSAFE CONDITION OR DEFECTIVE EQUIPMENT

The train and engine crews on Norfolk Southern are encouraged to fill out this form when unsafe conditions or defective equipment is found. Report the problem to your Supervisor on duty immediately and give a copy to the UTU Legislative Representative of UTU Local Chairman. Should Corrective action not be taken by Norfolk Southern, your Legislative Representative will then contact the Division Superintendent, the F. R. A. and the State Legislative Director. It is essential that we stand together and protect each other from serious injury.

Employee Name: ___________________________________________________________________________

Location: _________________________________________________________________________________

Date & Time: _____________________________________________________________________________

Supervisor Reported to: Name____________________TItle_________________Time________Method(radio/phone)______________

Description of Unsafe Condition or Defect: ______________________________________________________

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IMPORTANT!! NEED YOUR NAME, ADDRESS & PHONE NUMBER

Name: _____________________________________

Address: ___________________________________

Phone Number: ______________________________

Job Title: ___________________________________