United Transportation Union
Local 194 – Elkhart, Indiana
Health & Safety Complaint Form
TO: Norfolk Southern Railroad Co. Date:____________________
Attention:_____________________________
Several members of our local reported that the following unsafe condition exists:
Item:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_
Location:
______________________________________________________________________
______________________________________________________________________
____________________________________________________________________
Complaint:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_______
We hereby request that this unsafe situation be corrected and that I be advised when
completed.
____________________________
Legislative Representative
Reported to FRA Yes____________ No_____________, Awaiting RR
Reply__________
(A copy of this complaint should be retained in your local files. If unable to correct the
problem all documentation should be forwarded to our UTU office in Indianapolis, IN for
handling with the proper management officials and/or Federal & State agencies.)