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Legionnaires' Disease
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Appendix III:B-2. Sample Information to be Obtained by Interview with Employees Calling in on Sick Leave

Appendix III:B-2. Sample Information to be Obtained by Interview with Employees Calling in on Sick Leave

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).
STATEMENT

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: (____)________________________

Date: _____/_____/_____

PLEASE FORWARD TO ________________ BY 10:00 am EACH DAY

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