VBA 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: