DA Form 4755 Employee Report of Alleged Unsafe or Unhealthful Working Conditions

DA Form 4755 - also known as the "Employee Report Of Alleged Unsafe Or Unhealthful Working Conditions" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 4755 - was last revised on October 1, 1978. Download an up-to-date fillable PDF version of the DA 4755 down below or look it up on the Army Publishing Directorate website.

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EMPLOYEE REPORT OF
ALLEGED UNSAFE OR UNHEALTHFUL WORKING CONDITIONS
For use of this form, see DA PAM 385-10; the proponent agency is OCSA.
This form is provided for the assistance of any complainant and is not intended to constitute the exclusive means by which a complaint may be registered with the local Safety Office (Ref
OSHA Poster on rights of employees and their representatives).
The undersigned (check one)
Employee
Representative of employees
Other (Specify)
believes that a job safety or health hazard exists at the following place of employment
Does this hazard
immediately threaten serious physical harm?
Yes
No
(s)
If "yes" checked, immediately contact your supervisor or safety representative.
Telephone
Name of official in charge
Operation/Activity
Exact location of worksite
1. Kind of operation
2. Describe briefly the hazard which exists there including the appropriate number of employees exposed to or threatened by such hazard
3. List by number and/or name the particular occupational safety and health standard(s) which may have been violated, if known
4. (a) To your knowledge, has this hazard been the subject of any union/management grievance or have you (or anyone you know) otherwise called it to the attention of, or discussed
it with the employer or any representative thereof?
(b) If so, please give the results thereof, including any efforts by management to eliminate or reduce the severity of the hazard
5. Please indicate your desire:
I do not want my name revealed to the official in charge.
My name may be revealed to the official in charge.
WORK LOCATION
TELEPHONE NO.
DATE
TYPED OR PRINTED NAME OF EMPLOYEE OR EMPLOYEE REPRESENTATIVE
SIGNATURE
DA FORM 4755, OCT 1978
APD LC v2.01ES
EMPLOYEE REPORT OF
ALLEGED UNSAFE OR UNHEALTHFUL WORKING CONDITIONS
For use of this form, see DA PAM 385-10; the proponent agency is OCSA.
This form is provided for the assistance of any complainant and is not intended to constitute the exclusive means by which a complaint may be registered with the local Safety Office (Ref
OSHA Poster on rights of employees and their representatives).
The undersigned (check one)
Employee
Representative of employees
Other (Specify)
believes that a job safety or health hazard exists at the following place of employment
Does this hazard
immediately threaten serious physical harm?
Yes
No
(s)
If "yes" checked, immediately contact your supervisor or safety representative.
Telephone
Name of official in charge
Operation/Activity
Exact location of worksite
1. Kind of operation
2. Describe briefly the hazard which exists there including the appropriate number of employees exposed to or threatened by such hazard
3. List by number and/or name the particular occupational safety and health standard(s) which may have been violated, if known
4. (a) To your knowledge, has this hazard been the subject of any union/management grievance or have you (or anyone you know) otherwise called it to the attention of, or discussed
it with the employer or any representative thereof?
(b) If so, please give the results thereof, including any efforts by management to eliminate or reduce the severity of the hazard
5. Please indicate your desire:
I do not want my name revealed to the official in charge.
My name may be revealed to the official in charge.
WORK LOCATION
TELEPHONE NO.
DATE
TYPED OR PRINTED NAME OF EMPLOYEE OR EMPLOYEE REPRESENTATIVE
SIGNATURE
DA FORM 4755, OCT 1978
APD LC v2.01ES

Download DA Form 4755 Employee Report of Alleged Unsafe or Unhealthful Working Conditions

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