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March 26, 2017
 JED DODD
General Chairman
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Whistleblower Protection Report Form

Individuals working for railroad carriers are protected from retaliation for reporting potential safety or security violations to their employers or to the government.

Time Limit for Filing = 180 Days

BMWED Initial Report Form

Railroad Whistleblower Protection

49 U.S.C. §20109

* Required Fields


First Name: *
Last Name: *
Address: *
City, State: *,
Postal Code: - *

Phone: *
E-Mail Address: *
Railroad Employer:
Job Title:
Seniority Date:
Qualifications/Certifications:
Supervisor names/titles:
Name of Local BMWED Representative:
Name of personal attorney, if any:

What was your protected act?

Check all that apply

Did you make a complaint related to safety?

Did you report an accident, incident, and/or close call?

Did you report an injury, occupational illness, or a medical concern?

Did you request medical care, treatment, or advice related to your health?

How did the railroad become aware of your protected act?

Check all that apply

Did you complain to a foreman, supervisor, or member of management?

Did you complain to the Federal Railroad Administration?

Did you complain to a state railroad official?

Did you complain to any police agency?

Did you complain to any federal or state agency?

Did you complain to any member of Congress or staff member?

What was the method of your protected act?

Was your complaint or report in writing?

Was your complaint or report oral?

Was your complaint or report anonymous?

How did the Railroad know or suspect your protected act?

Did you inform the railroad?

Did someone else inform the railroad?

Do you know or know who?

Did you suffer an unfavorable personnel action?

Check all that apply

Firing

Suspended

Reprimanded

Disqualification

Demerits or Negative Points

Laid off

Abolishment of Job

Warning Letters

Offers of Waivers

Threats to take Action against Co-workers

Extra Safety Audits

Blacklisting

Demoting

Denying Overtime or promotion

Disciplining

Denying Benefits

Failing to hire or rehire

Intimidation

Reassignment Affecting Promotion Prospects

Reducing Hours or Pay

Isolation in question

Refusal to Accept Statement Submitted

Demands for Multiple or Repeated Statements

Failure to Provide First Aid

Failure to Promptly Arrange to be Taken to Hospital

Delay in Providing First Aid, Medical Care, Transport to Nearest Hospital

Other

When did the retaliatory act(s) occur?

Where did the retaliatory acts occur?
Do you have any supporting documentation?
Are there any witnesses to any of these retaliatory acts?
Provide a timeline of the case history:

Which is the best way to contact you?

 

Phone
Email
Old-fashioned U.S. Mail

When is the best time to contact you?

Daytime
Evening
Weekdays
Weekends

Additional Comments:

 


* Required Fields

 


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