Statement of Occurance

Statement of Occurrence

Please fill out all required fields with as much information as you can. Your Statement will be reviewed as soon as possible. Please contact us for more information.

Name

First Name

Last Name

Company Name

Work Location

Personal Email

Cell Phone

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Hire

Title

Supervisor's Name

Was disciplinary action taken?

What action did the company take?

Date of Occurrence: (MM/DD/YYYY)

The following is a statement of what happened to me on "Date of Occurrence"

What do you see as a resolution to this occurrence?

Please read and check button to authorize a "signed & dated" Statement of Occurrence.

I hereby give consent to the inspection by authorized Union Representatives any records which may affect my employment. This authorization is given in accordance with the agreement between the Union and the Company.