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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.
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* Indicates required question
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.
Yes
No
Other:
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.
Yes
No
Other:
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?
*
Yes
No
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