Novel Coronavirus Incident Intake Form

Fill out this Novel Coronavirus Incident Intake Form if you’ve had an issue at your workplace regarding the Coronavirus whether it is about protocol, staffing, worker or client safety, or urgent feedback that is falling on deaf ears. Our union is actively working with employers to ensure facilities and worksites have the equipment and supplies they need; that workers are trained in the right protocols for their job and workplace; and they are appropriately staffed but we need to hear about these incidents.

First Name*

Last Name*

Employee #*

Employer

Cellphone **

Personal Email

Healthcare Workers

Please check this box if you are healthcare worker in LA County (DHS, DPH, DMH), Riverside County (RUHS) and Ventura County (VCMC) and your question or concern is regarding workplace conditions, policies, health and safety compliance including but not limited to PPE accessibility, nurse to patient ratio compliance or other issues.

Region/Division*

IMPORTANT - Please make sure to select your Region/Division so we can route your incident to the correct person.

INCIDENT DETAiLS

Date of Incident

Time of Incident

Worksite/Location of Incident

Witnesses (if any)

Supervisor (who did you receive direction from?)

Describe the Incident*

(What happened? Describe the sequence of events.)

**By providing my phone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and/or text message me on my cellular phone on a periodic basis. SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. To unsubscribe, text STOP at 31996. For info, text HELP at 31996.

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INCIDENT DETAiLS