| CROSS JURISDICTION
FORM |
| Questions marked by * are required.
If you do not know the answer, please type "Unknown." |
| 1. |
Location of Incident: *
|
| 2. |
Your Name: *
|
| 3. |
Your Home Phone Number: *
|
| 4. |
Your Personal Email: *
|
| 5. |
Contracts involved: *
|
| 6. |
Contracts Employees Working in: *
|
| 7. |
Department Working in: *
|
| 8. |
Department Employee is Coming From: *
|
| 9. |
Supervisor of the Area Where the Work is Being Performed:
*
|
| 10. |
Supervisor’s Phone Number: *
|
| 11. |
Name of the Supervisor Whose Employee is Working in the Area:
*
|
| 12. |
Telephone Number of the Supervisor: *
|
| 13. |
Type of Work Performed: *
|
|
(Once submitted, a copy of the answers will be sent to the
email address you provided.)
RLS/jl
opeiu3, afl-cio
|
