When Railroad Says Your Injury Is Non-Occupational

Name:

Address:

City:

State:

Zip:

Country:

Home Phone:

Cell Phone:

Email:

Railroad employed by:

Occupation:

Date of work injury:

Nature of injury:

Location of injury:

Date reported injury

Summary description of how and why your injury occurred:

Does your treating doctor believe your injury is workrelated?

What was the date the Railroad's OHS or Medical Department declared that your injury was non-occupational, or not related to your work?

What was the final or actual discipline the Railroad assessed against you?

What was the date of the final or actual discipline assessed against you?

Explain how the Railroad did not have any reasonable basis for disciplining or retaliating against you--in other words, explain how you did not actually violate the safety rules or procedures the Railroad says you violated:

Please give the name and phone numbers of any witnesses with knowledge of this situation: for example, any co-workers and union representatives who can confirm you were injured on the job.