REPORT A VIOLATION
Record
the Facts: Who / What / When / Where
In
the event you believe that management personnel violated the Federal Law in any
way, please complete this form and return it to your IAM Representative without
hesitation. When completing this form, please be as specific as possible about
the incident including direct quotes.
On
or about __________________, _____, at _________, in or near
(Date)
(Year)
(Time)
_____________________________________,
the following named
(Place Incident Occurred)
management
personnel _______________________were involved in the
(Names
and Titles)
below described incident:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
This incident was also witnessed by:
____________________________________________________________
(If
additional space is needed, write on reverse side)
Name (Please Sign) ___________________________________________
Address: ____________________________________________________
___________________________________________________________
Date of Statement: ____________________________________________