AFGE Local 609
  • April 04, 2020
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  • VHA Intake Form

    INTAKE FORM

    Date:
    Employee Name:
    Personal Email Address:

    Department/Clinic:
    Job Title:
    Series/Grade:
    1st Line Supervisor:
    2nd Line Supervisor:
    Work Location:
    Cell Phone:
    Home Phone:
    Home Address:

    Summary of Complaint

    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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