Get Da 4755

WORK LOCATION TYPED OR PRINTED NAME OF EMPLOYEE OR EMPLOYEE REPRESENTATIVE DA FORM 4755 OCT 78 TELEPHONE NO. EMPLOYEE REPORT OF ALLEGED UNSAFE OR UNHEALTHFUL WORKING CONDITIONS For use of this form see AR 385-10 the proponent agency is Office of The Inspector General* 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 s immediately threaten serious physical harm If yes checked immediately contact your supervisor or safety representative. Yes No 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. EMPLOYEE REPORT OF ALLEGED UNSAFE OR UNHEALTHFUL WORKING CONDITIONS For use of this form see AR 385-10 the proponent agency is Office of The Inspector General* 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 s immediately threaten serious physical harm If yes checked immediately contact your supervisor or safety representative. 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 s immediately threaten serious physical harm If yes checked immediately contact your supervisor or safety representative. Yes No Telephone Name of official in charge Operation/Activity Exact location of worksite 1. Kind of operation 2. Yes No 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.