In the world of workplace safety and health management, the DA Form 4755 plays a crucial role, serving as a pivotal communication tool for employees to report alleged unsafe or unhealthful working conditions. Originating from the guidelines provided in AR 385-10 and backed by the Office of The Inspector General, this form stands as a testament to the commitment towards ensuring a safe working environment for all. Its design caters to both employees and their representatives, offering a systematic way to voice concerns about job safety and health hazards. Not only does it encourage individuals to bring attention to potential risks, but it also respects the wish of anonymity for those who prefer it, thereby fostering an atmosphere where safety issues can be reported without fear of reprisal. Whether the danger presented is immediate or a looming threat, the form guides the reporter through detailing the specific nature of the hazard, the number of employees exposed, and any violations of occupational safety and health standards that may have occurred. Furthermore, it inquires about any past efforts to address the hazard, whether through union/management grievances or discussions with the employer, thus providing a comprehensive overview of the situation at hand. This inclusive approach underlines the significance of the DA Form 4755 in promoting a proactive stance on workplace safety, emphasizing the collective responsibility of employers and employees in creating a secure and healthful working environment.
| Question | Answer |
|---|---|
| Form Name | Da Form 4755 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | army da form 4755, da form 4755, DA, da 4755 form |
EMPLOYEE REPORT OF
ALLEGED UNSAFE OR UNHEALTHFUL WORKING CONDITIONS
For use of this form, see AR
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 |
believes that a job safety or health hazard exists at the following place of employment
Other (Specify)
Does this hazard (s) immediately threaten serious physical harm? |
Yes |
No |
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If "yes" checked, immediately contact your supervisor or safety representative. |
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Name of official in charge |
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Telephone |
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Operation/Activity |
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Exact location of worksite |
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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 |
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TELEPHONE NO. |
DATE |
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TYPED OR PRINTED NAME OF EMPLOYEE OR EMPLOYEE |
SIGNATURE |
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REPRESENTATIVE |
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DA FORM 4755, OCT 78
USAPPC V1.00