CWA Coronavirus Infectious Disease Incident Tracking Form
DISCLAIMER: In addition to filling out this form, please use your employer's normal reporting process and engage with your Local Union.
Date *
Today's Date
Your answer
First Name *
Your answer
Last Name *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
CWA Local *
Your answer
Employer *
Your answer
Job Title *
Your answer
What is your work site location? *
Your answer
Please provide a description of your assignment and/or duties on the job *
Your answer
What symptoms are you experiencing? *
Your answer
When did you start to experience these symptoms? *
MM
/
DD
/
YYYY
Have you experienced these symptoms while on the job? *
If no, please put 'N/A' in the next question and move on to the following question.
If Yes, since when? *
Please provide exact date. Ex: Feb.24, 2020
Your answer
Have you notified your employer? *
If no, please put 'N/A' in the next question and move on to the following question.
If yes, when did you notify you notify your employer? *
Please provide exact date. Ex: Feb.26, 2020
Your answer
What was your employer's response? *
Your answer
Please list and describe any and all possible sources of exposure *
Your answer
This form was filled out by the CWA member listed above? *
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