Injured Workers Form

First Name *

Last Name *

Preferred Name

Unit *

Employee Number *

Preferred Phone Number *

Preferred Email *

If selected Other

Brief description of what happened *

Would you like to be contacted by the Union Representative for follow-up and support? *

Yes

Thanks for your submission. All information will be kept in confidence. If you like any further information, please contact your Union Steward or the Injured and Ill worker Representative at injuredworkers@cupe905.com

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Injured Workers Form

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