Brotherhood of Locomotive Engineers and Trainman

Federal Hours of Service - Violation Report

EMPLOYEE INFORMATION

Full Name:

Phone Number:

Email Address:

Address:

Occupation:

Employing Railroad:

ADDITIONAL CREW MEMBER

Full Name:

Phone Number:

Email Address:

Address:

Occupation:

CREW SERVICE INFORMATION

Train ID:

On Duty Information

Time:

Date:

Location (City and State):

List who and at what time you contacted them about the limitations of your hours of service:

(Example: I contacted Dispatcher at 11:00 that my hours of service were up at 12:00; or I informed Yard Master I had 30 minutes left to work):

Stopped Train At:

Time:

Date:

Nearest Station:

Time Relieved from Service:

(Time you finished tying down your train, and/or are instructed to relieve yourself )

Total Time on Duty:

(Total time from on duty time to time relieved from service, deadhead transportation to final terminal is limbo time, not on duty time)

Mode of deadhead transportation:

Time Released from Service:

(Tie up time at home terminal or away-from-home terminal)

Location Released from Service (City & State):

Please enter remarks as needed to explain the cause of hours of service violation. All appropriate remarks will be used:

This information will be reviewed by representatives of BLET 622 and then forwarded to your BLET State Legislative Chairman for further action.