BLET 244

HOS Violation Form

This form was created in an effort to easily submit and collect information on the excessive HOS violations experienced in our division. Hopefully, with documentation, we can help facilitate some changes for the betterment of our workplace and community. Please use the red box labeled "Attach file to Form" to attach a copy of your timeslip.

BLET Division 244

HOS Violation Form

First Name & Last Name:
Phone number:
Email Address:
Occupation:
--------------------------------------	------------------------------------------------------------------------------------------------------------------------------------------------------------
Have you, or plan to, turn this information to the FRA yourself?	Yes No
-------------------------------------	Your crew information:
Train symbol:
On-duty date:
On-duty time:
Your crew:	Conductor: Engineer:
--------------------------------------	Relief crew information:
Relief crew:	Conductor: Engineer:
Relief crew on-duty date:
Relief crew on-duty time:
-------------------------------------	Limo information:
	Ask the driver for this information.
Limo order time:
Limo arrival time:
-------------------------------------	HOS information:
Did you work past 12 hours? If so, how long?	Yes No
Who authorized?
Radio channel:
Lead Locomotive Number: