GSA3592
GSA Employee Report of Unsafe or Unhealthy Working Conditions
GSA Form 3592, GSA Employee Report of Unsafe or Unhealthy Working Conditions, is a two-page GSA form. The footer reads GENERAL SERVICES ADMINISTRATION and GSA FORM 3592 (7-92), and GSA hosts it in its forms library.
The back of the form says that, 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. It says employees are urged to report conditions verbally to their supervisors, and that use of the GSA Form 3592 is required for a written report. The front asks for the facility and location, the supervisor, a description of the hazard, any injury or damage, whether the employee's name may be revealed, and the employee's name, signature and date.
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A Regional S&EM report number block, and a notice to verbally inform the regional Safety and Environmental Management office about an imminent danger or a condition that could cause immediate serious physical harm.
Employee or representative, the GSA facility name and mailing address, the location of the alleged violation, the supervisor at the site and phone number, and whether the condition was reported to the supervisor.
A description of the hazard, including materials and equipment involved and the approximate number of employees exposed, any GSA standard violated, any attempt to correct it, and whether anyone was hurt or property damaged.
A yes or no confirming the reporting and appeal procedures on the back were read and understood, and a yes or no on whether the employee's name may be revealed.
The employee's name and address, telephone number with area code, signature and date.
The rules for written responses, investigation times, appeals and anonymity.
The form says that for an imminent danger, or a condition that could cause immediate serious physical harm, the regional Safety and Environmental Management office should be verbally informed to expedite correction.
Check employee or representative in item 1, then enter the facility, the location of the alleged violation and the supervisor at the site in items 1(a) to 3.
Complete items 4 to 6(a): the hazard, materials and equipment, the approximate number of employees exposed, any GSA standard violated, attempts to correct it, and any injury or property damage.
The form says that to remain anonymous, the response to Block 8 must be NO, and that the S&EM office will detach the bottom portion before distribution.
The form says that if Block 9 is not completed, no written reply will be made, though that does not preclude an investigation and tracking of the matter.
Sign and date item 10, then give the form to a supervisor, manager, OSH committee or S&EM office.
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Supervisors, managers, OSH committees or S&EM offices who receive a completed form respond in writing to the employee, regardless of the findings, and officials in charge of GSA workplaces keep a local procedure for tracking written reports.
If the S&EM office receives the report, the form says an investigation is to commence within 24 hours for an alleged imminent danger condition, 3 days for serious conditions and 20 days for all other alleged conditions.
The form lists the Establishment OSH Committee, then the S&EM office in writing, then in turn the Region DASHO, GSA DASHO and the Secretary of Labor, who is the final authority.
The form says no reprisal or coercion of any kind will be taken against an employee who reports an unsafe or unhealthful workplace condition.
Executive Order 12196 and Title 29, Code of Federal Regulations, part 1960. Investigation instructions are in Chapter 2-5 of the Handbook, GSA Occupational Safety and Health Program (ADM P 5940.1).
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The Reporting/Appeal Procedures on the back describe who reports and who receives the form.
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The footer reads GENERAL SERVICES ADMINISTRATION and GSA FORM 3592 (7-92). GSA hosts it in its forms library.
The form says GSA employees are urged to report conditions verbally to their supervisors, and that if the employee wants to report the condition in writing, use of the GSA Form 3592 is required.
The form says the response to Block 8 must be NO to remain anonymous, the S&EM office will detach the bottom portion before distribution, and the request for anonymity will not be violated by a GSA official receiving the report.
The form says no written reply will be made by the GSA official receiving the report, but that this does not preclude an investigation of the matter and tracking until its final conclusion.
When the S&EM office receives it, the form says within 24 hours for an alleged imminent danger condition, 3 days for serious conditions and 20 days for all other alleged conditions.
The form lists appeals to the Establishment OSH Committee, then the S&EM office, then in turn the Region DASHO, GSA DASHO and the Secretary of Labor, who is the final authority.