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Hours of Service Violation Form
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Email *
Job Title  *
Name *
Phone *
Job Title (other crew member) *
Name
Phone
Division *
Email
Train ID *
On Duty Time *
Time
:
On Duty Date *
MM
/
DD
/
YYYY
On Duty Location (City or Town, NOT CRIC-7) *
Which Railroad do you work for? *
Required
Who was Notified of HOS? *
Required
Specify name Title and Times contacted *
Radio Chanel (so the FRA can pull the tapes)
Stopped Train at Location (Siding, Terminal, or Mile Post) *
Stopped Train Time *
Time
:
Stopped Date *
MM
/
DD
/
YYYY
Where you Instructed to NOT tie down the train? If you answer yes, please fill out the next question. *
By whom
Relief crew Engineer
Relief Crew conductor
Time Relief crew was Ordered
Time
:
Origin Station of Relief Crew
Mode of transportation
Clear selection
If van, time van was called
Driver name
Van number
Time van arrived at the Train  *
Time
:
Time Relived from Train (Must show an HOS violation when filling out your tie up ticket with the Railroad) *
Time
:
Time released from service *
Time
:
Date Release from service *
MM
/
DD
/
YYYY
Location released from service *
Total Time on Duty *
Do You want to Report Anonymous? *
Additional Information (Please give as mush details as possible) *
Once Completed Please Email a copy of your tie up slip to Benwright@txslb.org 
A copy of your responses will be emailed to the address you provided.
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