GSA_3592_Unhealthy_Unsafe_Working_Conditions.pdf

YES NO

9(a). EMPLOYEE'S TELEPHONE NUMBER (Include Area Code)

REGIONAL S&EM

REPORT NO.

1. (Check one)

2. NAME OF SUPERVISOR AT SITE OF VIOLATION

EMPLOYEE

REPRESENTATIVE OF EMPLOYEE

BELIEVES THAT A CONDITION IN

THE WORKPLACE VIOLATES GSA

OCCUPATIONAL SAFETY AND

HEALTH STANDARDS

1(a). NAME OF GSA FACILITY AND MAILING

ADDRESS

1(b). LOCATION OF ALLEGED VIOLATION

2(a). TELEPHONE NUMBER OF SUPERVISOR AT SITE

OF VIOLATION

3. HAVE YOU REPORTED THIS CONDITION

TO YOUR SUPERVISOR?

4. DESCRIBE THE HAZARD, INCLUDE MATERIALS AND EQUIPMENT INVOLVED AND THE APPROXIMATE NUMBER OF EMPLOYEES EXPOSED OR THREATENED BY THE

CONDITION

5. IF KNOWN, LIST THE GSA STANDARD VIOLATED

6. HAS ANYONE ATTEMPTED TO CORRECT THE

CONDITION? IF YES, GIVE DETAILS.

6(a). HAS ANYONE BEEN HURT, OR HAS PROPERTY BEEN DAMAGED AS A

RESULT OF THIS CONDITION?

NO YES YES NO IF YES, GIVE DETAILS.

YES NO

7. I HAVE READ AND UNDERSTOOD THE REPORTING AND APPEAL PROCEDURES OUTLINED ON THE BACK OF THIS FORM.

8. MAY YOUR NAME BE REVEALED?

IF NO IS CHECKED, S&EM OFFICE WILL DETACH BOTTOM PORTION OF THIS FORM BEFORE DISTRIBUTION IS MADE.

YES NO

9. EMPLOYEE'S NAME AND ADDRESS (Type or printed)

10. EMPLOYEE'S SIGNATURE DATE

GSA FORM 3592 (7-92)

GSA EMPLOYEE REPORT OF UNSAFE OR UNHEALTHY WORKING CONDITIONS

SHOULD YOU CONSIDER THIS CONDITION TO BE AN IMMINENT DANGER, OR OF A TYPE THAT COULD CAUSE IMMEDIATE SERIOUS PHYSICAL HARM, PLEASE VERBALLY INFORM THE REGIONAL SAFETY AND ENVIRONMENTAL MANAGEMENT OFFICE

TO EXPEDITE CORRECTION.

GENERAL SERVICES ADMINISTRATION

Reporting/Appeal Procedures

In accordance with Executive Order 12196 and Title 29, Code of Federal Regulations, part 1960, every GSA employee has the right to report what he/she perceives to be an unsafe or unhealthful condition in the GSA workplace. GSA managers/supervisors have the responsibility to investigate the employee's report whether verbal or written. Furthermore, no reprisal or coercion of any kind will be taken against an employee who reports an unsafe or unhealthful workplace condition.

GSA employees are urged to report known or suspected unsafe or unhealthful workplace conditions verbally to their supervisors. However, if the employee desires to report the condition in writing, use of the GSA Form 3592 is required. Supervisors, managers, OSH committees, or Safety and Environmental management (S&EM) offices who receive a completed GSA Form 3592 from a GSA employee must respond in writing to the employee, regardless of the findings. Furthermore, officials in charge of GSA workplaces must implement a local procedure for tracking written reports and subsequent action(s) taken in support of the report regardless of the findings.

Employees who are not satisfied with the written response from the supervisor, have the right of appeal to the Establishment OSH Committee who shall investigate the matter promptly.

The OSH Committee must report their findings to the employee. The employee may report the matter in writing to the S&EM office if he/she is not satisfied by the committee's response.

If the S&EM office receives the report, a report number will be assigned (see upper right block on the Form 3592) and an investigation of the allegation is to commence within 24 hours for an alleged imminent danger condition; 3 days for serious conditions; 20 days for all other alleged conditions. Instructions regarding investigation of an employee report of unsafe or unhealthful workplace condition are contained in Chapter 2-5 of the Handbook, GSA Occupational Safety and Health Program (ADM P 5940.1). The S&EM office will ensure that appeal procedures are contained in the response to the employee. Specially, in GSA, if dissatisfied with the response from the S&EM office, the employee may appeal (in turn) to the Region DASHO, GSA DASHO, and Secretary of Labor who is the final authority.

The information required to be entered on the GSA Form 3592 is self-explanatory. If it is an employee's desire to remain anonymous, the response to Block 8 must be NO. Under no circumstances will the request for anonymity be violated by a GSA official receiving the report.

If Block 9 is not completed, no written reply will be made by the GSA official receiving the report. This does not preclude an investigation of the matter and tracking until its final conclusion.

YES

NO

9(a). EMPLOYEE'S TELEPHONE NUMBER (Include Area Code)

REGIONAL S&EM REPORT NO.

1. (Check one)

2. NAME OF SUPERVISOR AT SITE OF VIOLATION

EMPLOYEE

REPRESENTATIVE OF EMPLOYEE BELIEVES THAT A CONDITION IN THE WORKPLACE VIOLATES GSA OCCUPATIONAL SAFETY AND HEALTH STANDARDS 1(a). NAME OF GSA FACILITY AND MAILING ADDRESS 1(b). LOCATION OF ALLEGED VIOLATION 2(a). TELEPHONE NUMBER OF SUPERVISOR AT SITE

OF VIOLATION

3. HAVE YOU REPORTED THIS CONDITION

TO YOUR SUPERVISOR?

4. DESCRIBE THE HAZARD, INCLUDE MATERIALS AND EQUIPMENT INVOLVED AND THE APPROXIMATE NUMBER OF EMPLOYEES EXPOSED OR THREATENED BY THE CONDITION

5. IF KNOWN, LIST THE GSA STANDARD VIOLATED

6. HAS ANYONE ATTEMPTED TO CORRECT THE

CONDITION? IF YES, GIVE DETAILS.

6(a). HAS ANYONE BEEN HURT, OR HAS PROPERTY BEEN DAMAGED AS A

RESULT OF THIS CONDITION?

NO

YES

YES

NO

IF YES, GIVE DETAILS.

YES

NO

7. I HAVE READ AND UNDERSTOOD THE REPORTING AND APPEAL PROCEDURES OUTLINED ON THE BACK OF THIS FORM.

8. MAY YOUR NAME BE REVEALED?

IF NO IS CHECKED, S&EM OFFICE WILL DETACH BOTTOM PORTION OF THIS FORM BEFORE DISTRIBUTION IS MADE.

YES

NO

9. EMPLOYEE'S NAME AND ADDRESS (Type or printed)

10. EMPLOYEE'S SIGNATURE

DATE

GSA FORM 3592 (7-92)

GSA EMPLOYEE REPORT OF UNSAFE OR UNHEALTHY WORKING CONDITIONS

SHOULD YOU CONSIDER THIS CONDITION TO BE AN IMMINENT DANGER, OR OF A TYPE THAT COULD CAUSE IMMEDIATE SERIOUS PHYSICAL HARM, PLEASE VERBALLY INFORM THE REGIONAL SAFETY AND ENVIRONMENTAL MANAGEMENT OFFICE TO EXPEDITE CORRECTION.

GENERAL SERVICES ADMINISTRATION

Reporting/Appeal Procedures In accordance with Executive Order 12196 and Title 29, Code of Federal Regulations, part 1960, every GSA employee has the right to report what he/she perceives to be an unsafe or unhealthful condition in the GSA workplace. GSA managers/supervisors have the responsibility to investigate the employee's report whether verbal or written. Furthermore, no reprisal or coercion of any kind will be taken against an employee who reports an unsafe or unhealthful workplace condition.

GSA employees are urged to report known or suspected unsafe or unhealthful workplace conditions verbally to their supervisors. However, if the employee desires to report the condition in writing, use of the GSA Form 3592 is required. Supervisors, managers, OSH committees, or Safety and Environmental management (S&EM) offices who receive a completed GSA Form 3592 from a GSA employee must respond in writing to the employee, regardless of the findings. Furthermore, officials in charge of GSA workplaces must implement a local procedure for tracking written reports and subsequent action(s) taken in support of the report regardless of the findings.

Employees who are not satisfied with the written response from the supervisor, have the right of appeal to the Establishment OSH Committee who shall investigate the matter promptly. The OSH Committee must report their findings to the employee. The employee may report the matter in writing to the S&EM office if he/she is not satisfied by the committee's response. If the S&EM office receives the report, a report number will be assigned (see upper right block on the Form 3592) and an investigation of the allegation is to commence within 24 hours for an alleged imminent danger condition; 3 days for serious conditions; 20 days for all other alleged conditions. Instructions regarding investigation of an employee report of unsafe or unhealthful workplace condition are contained in Chapter 2-5 of the Handbook, GSA Occupational Safety and Health Program (ADM P 5940.1). The S&EM office will ensure that appeal procedures are contained in the response to the employee. Specially, in GSA, if dissatisfied with the response from the S&EM office, the employee may appeal (in turn) to the Region DASHO, GSA DASHO, and Secretary of Labor who is the final authority.

The information required to be entered on the GSA Form 3592 is self-explanatory. If it is an employee's desire to remain anonymous, the response to Block 8 must be NO. Under no circumstances will the request for anonymity be violated by a GSA official receiving the report.

If Block 9 is not completed, no written reply will be made by the GSA official receiving the report. This does not preclude an investigation of the matter and tracking until its final conclusion.

8.2.1.4029.1.523496.503679