BLET Division 98 Lincoln, NE

EMPLOYEE INFORMATION
Name:
Phone:
Email:
Address:
City, State:	,
Zip:
Occupation:	Engineer Conductor Brakeman Other:
Employing Railroad:
Railroad Responsible (if different):
ADDITIONAL CREW MEMBER
Name:
Phone:
Email:
Address:
City, State:	,
Zip:
Occupation:	Engineer Conductor Brakeman Other:
*CREWS SERVICE INFORMATION*
Train ID:
ON DUTY	Time: Date: Location: State:
NOTIFIED	Dispatcher Yard Master of duty limitations at: &
STOPPED train at	Time: Date: Nearest Station: State:
TIME relieved from service:	(Time you finish tying down train, and/or are instructed to relieve yourself)
TOTAL TIME ON DUTY per HOURS OF SERVICE ACT:	HRS MINS (Total time from on-duty to time relieved from service, deadhead transportation to final terminal is limbo time, not OD time)
MODE of deadhead transportation:	Contract Van Company Van Train Other:
TIME deadhead transportation began:
TIME deadhead transportation ended:
TIME released from service: (Tie up time at Home or Away Terminal)	Time: Date: Location: State:
Please enter remarks as needed to explain cause of HOS violation. All appropriate remarks will be used.
Remarks:
Attach time slip and any other supporting documentation such as delays using the upload button at the top of this form - before clicking Submit below.