Member details First name * Surname * Email * Contact number Membership number * Trade Union details Union * Region * Branch * Name of employer * Approximate date of exposure to COVID-19 * Place of exposure to COVID-19 * Date COVID-19 symptoms started * Has the member been tested for COVID-19 * - Has the member been tested for COVID-19 * -YESNO Positive COVID-19 test date * PPE provided by employer * - PPE provided by employer * -YESNO If PPE was provided what PPE was given to the member * Was the issue of a lack of PPE notified to the employer - Was the issue of a lack of PPE notified to the employer -YESNO Union rep involved (if yes, name of rep) * Have you raised a grievance (individual or collective) * Have other employees tested positive for COVID-19 * - Have other employees tested positive for COVID-19 * -YESNO Have any members of your household tested positive for COVID-19 * - Have any members of your household tested positive for COVID-19 * -YESNO How do you travel to and from work * Do you have any underlying health conditions you are aware of * - Do you have any underlying health conditions you are aware of * -YESNO Did you receive SSP or full pay while self-isolating * If you had sick leave did you receive SSP or full pay * If you were off sick, was any sickness absence counted against other absences * If you received company sick pay was this in place from day one * - If you received company sick pay was this in place from day one * -YESNO Agreement to share information with your Union * - Agreement to share information with your Union * -YESNO Submit
