Da 4755, 1978, Report Of Alleged Unsafe Or Unhealthful Working Conditions

EMPLOYEE REPORT OF

ALLEGED UNSAFE OR UNHEALTHFUL WORKING CONDITIONS

For use of this form, see DA PAM 385-10; the proponent agency is OCSA.

This form is provided for the assistance of any complainant and is not intended to constitute the exclusive means by which a complaint may be registered with the local Safety Office (Ref

OSHA Poster on rights of employees and their representatives).

The undersigned (check one)

Employee

Representative of employees

Other (Specify)

believes that a job safety or health hazard exists at the following place of employment

Does this hazard

immediately threaten serious physical harm?

Yes

No

(s)

If "yes" checked, immediately contact your supervisor or safety representative.

Telephone

Name of official in charge

Operation/Activity

Exact location of worksite

1. Kind of operation

2. Describe briefly the hazard which exists there including the appropriate number of employees exposed to or threatened by such hazard

3. List by number and/or name the particular occupational safety and health standard (s) which may have been violated, if known

4. (a) To your knowledge, has this hazard been the subject of any union/management grievance or have you

(or anyone you know) otherwise called it to the attention of, or discussed

it with the employer or any representative thereof?

(b) If so, please give the results thereof, including any efforts by management to eliminate or reduce the severity of the hazard

5. Please indicate your desire:

I do not want my name revealed to the official in charge.

My name may be revealed to the official in charge.

WORK LOCATION

TELEPHONE NO.

DATE

TYPED OR PRINTED NAME OF EMPLOYEE OR EMPLOYEE

SIGNATURE

REPRESENTATIVE

DA FORM 4755, OCT 1978

APD PE v2.00