UNITED TRANSPORTATION UNION
HARASSMENT/INTIMIDATION
INJURY REPORT
I feel that I have been harassed and/or intimidated by officers or employees of
______________________Railroad after I was injured on the job.
Date of Injury:______________________________________________________
Place of Injury:______________________________________________________
Person Who Harrassed
Or Intimidated Me:_________________________His/Her Title:______________
Circumstances of
Harrassment/Intimidation:__________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_________________________________________
I was threatened with
Disciplinary Action: Yes_________ No___________
By Whom:_________________________________________________________
When:_____________________________________________________________
Where:____________________________________________________________
How:__________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
__________________________________________________
Mail to: Name:______________________________________
Your Local Local:_______________________________________
Legislative Representative
SSN:_____/_____/_____Phone:__________________
Date:_______________________________________