Interviewer: __________________________ Date: _____/_____/_____
SUPERVISOR SURVEY FORM
We are screening employee illnesses as a result of our Legionnaire's disease incident. You are not obligated to participate in the survey, but your participation will help you and your fellow workers.
We recommend that you see a physician if you currently have pneumonia-like symptoms such as severe chills, high fever, a cough, and difficult breathing.
Are you currently experiencing these symptoms?
Yes_____ No_____ Prefer not to answer______
- If the answer to the question is "No," do not complete the rest of this form. Thank you for your cooperation.
- If the answer is "Yes," please read the statement below and complete the bottom half of this form (Employee name, etc).
- If you answer is "Prefer not to answer," please complete ONLY the bottom half of this form (Employee name, etc).
You will be contacted by _________________________ to obtain additional information necessary to complete our survey. Thank you!
Employee's Name (please print): _______________________________________________
Work Telephone Number: (____)__________________________
Home Telephone Number: (____)__________________________
Shift: Day ___ Swing ___ Graveyard ___ Rotating ___
Branch: _______________________ Organization Code: _______________
Employee's Supervisor (please print): _____________________________________________
Telephone Number: (____)________________________
PLEASE FORWARD TO ________________ BY 10:00 am EACH DAY