Chicago Division

Safety Issue Resolution

Unsafe Condition/Safety Concern

Report Form

Instructions

1.      E   1.  EACH REPORT SHOULD BE TAKEN TO THE RESPONSIBLE FIRST LINE SUPERVISOR.

2.  If there is no resolution/response given in seven (7) days, fax COMPLETED form to Division Safety Manager at 773-579-5178.

3.   Submitting employees will be notified (by phone or type written letter) within seven (7) days upon receipt of the report.

Your Name: _____________________________ E-mail:______________________________

Address: ________________________________ Phone Number: _______________________

Job T 

J Job   Job Title & Work Location: _____________________________________________________

Craft:   

MO     MOW ________ TY&E ________ MEC________ Signal ________ Other _________

Date: 

DDD   Date:_______________ Time: ____________ Train Symbol: __________________________

Loca    Location: ________________________________ Mile Post: ___________________________

ConC  Concern/Description:

Reco    Recommend Solution:

Was   

            Was this form given and brought to the immediate attention of a Chicago Division Officer?

IF yI  

            If yes, who? ________________________________  Date: ___________________________

Have 

            Have you been been contacted within seven ( 7 ) days?  Yes _____  No_____

Officer Information

ISSS     Issue forwarded to ________________________ for completion on _________________________.

Date   

             Date resolution received? _________________ Date Completed: __________________________.