HWR NY COVID Incident Report
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Organizer Name *
First Name *
Last Name *
Phone Number *
Email Address
Type of Concern
Date problem started
MM
/
DD
/
YYYY
Employer
Brief description of the problem *
How did the employer notify or contact you about the issue?
Clear selection
What day did you receive the notification?
MM
/
DD
/
YYYY
How did you notify or contact the employer about the issue?
Clear selection
What day did you send the notification?
MM
/
DD
/
YYYY
How did you respond or follow up with the employer?
Clear selection
What day did you respond?
MM
/
DD
/
YYYY
Who did you speak to?
Brief description of the result
Please write any additional notes here
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