Brotherhood of Locomotive Engineers
Division 758
This report should be used in the event something happens to you, but you are not sure an injury was incurred. Please take precautions against being cited for a late report.
BURLINGTON NORTHERN SANTA FE
Non-Reportable Injury
Follow-up Instructions
After submitting a First-Aid notification, you, as an employee, have the following responsibilities:
1. Promptly notify your supervisor before visiting a health care professional for treatment or observation of your injury.
2. Promptly notify your supervisor if you experience any complications resulting from your injury.
3. Promptly notify your supervisor if you are unable to perform your normal job duties.
4. Promptly notify your supervisor if you need to absent yourself from your regular job assignment as a result of your injury.
5. Promptly notify your supervisor if a health care professional prescribes prescription medication for treatment of your injury.
If you have any questions, regarding these instructions, you are instructed to immediately contact your supervisor.
By signing below, you acknowledge receiving these instructions and understanding the content of these instructions and further acknowledge that you have been afforded the opportunity to ask any questions regarding these instructions.
Employee Signature: ________________________________ Date: __________________
Employee Name: (PRINT)____________________________
Employee SSA:
________________________Date of Injury: ________________
Supervisor Name:
_____________________Supervisor Phone Number: _____________________