AFSCME Members Killed on the Job Report Form

AFSCME Members Killed on the Job Report Form

Use this form to report the death of an AFSCME member killed on the job. Please fill out as much information about the death as you can. This form will go to AFSCME's Health and Safety staff for verification and addition to our database.

*Items in bold with an asterisk are required.
First Name:
Last Name:
Address:
City:
State:
Zip: (xxxxx-xxxx)
Council/Affiliate:
Local:
Workplace:
Date: (MM/DD/YYYY)
Industry:
Cause of death:
Write a brief description of the circumstances of death:
CONTACT INFORMATION FOR YOU:
First Name:
Last Name:
Address:
City:
State:
Zip: (xxxxx-xxxx)
Email Address:
Phone: (xxx-xxx-xxxx)
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