Issue Intake Form

INTAKE FORM

Date:

Employee Name:

Personal Email Address

:Work Location

HR Location

Title 5, Title 38 Hybrid

1st Line Supervisor:

Supervisor phone #

best time to get ahold of you

Cell Phone:

Home Phone:

Home Address:

Summary of Complaint

Please let us know if you do not work directly for the VHA at WTS. Are you Prosthetics? Optical Lab? Office of Community Care?

Is your HR located in Denver Co. or Dayton OH? The local deals with 20 worksites, and 4 HR sties..

Date of Incident:

Time of Incident:

Location of Incident:

What happened that caused you to contact the Union:

Is this a repeat occurance:

Yes No

If Yes, give the date & time of first offense:

List Details: What did you see, Who said what, What specific actions were taken and by whom, list in chronological order you may attach addition page:

Have you already discussed this with anyone in management:

Yes No

If Yes, Who:

What did they say:

Are there any witnesses involved

Yes No

If Yes, provide the following:

Name:

Phone Number:

Name:

Phone Number:

Name:

Phone Number:

What remedy do you want or what will make you whole again:

Signature:

Date:

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