Technology Event

Member Information

First Name

The First Name field is required.

Last Name

The Last Name field is required.

Local

The Local field is required.

Carrier

The Carrier field is required.

General Committee

The General Committee field is required.

Craft

The Craft field is required.

Member Type

The Member Type field is required.

Contact Information

I would like to be contacted by a union officer?

YesNo

Email Address

Phone

The Phone field is required.

Railroad Technology Event Details

Date of Incident

The On Duty Date / Time field is required.

In what State did the event occur?

The State field is required.

Location of the Event
(Division / Subdivision / Yard, etc.)

The Event Location field is required.

Locomotive Initials / ID that had the incident

The Locomotive Initials / ID field is required.

Train ID

The Train ID field is required.

Type of Event

The Event Type field is required.

If the event was not listed in selections above, please provide other event details

Milepost of Event

Event, On Duty, Off Duty Time Format

Military AM/PM

Time of Event

On Duty Time

Off Duty Milepost

Off Duty Date

Off Duty Time

What was the length of the train when the event happened?

Was the train a key train?

YesNo

Have you been or feel you may have been retaliated against for reporting this?

YesNo

In the textbox below, please list other
details or facts that you feel may be pertinent to our efforts and/or that were not addressed in the questions above (optional).

Optional File Upload to attach to this report
(pdf, jpeg, bmp, tiff, png)