Exit GMB/UnionLine Covid-19 Questionnaire Question Title * 1. Name of member Question Title * 2. Member contact number Question Title * 3. Member email address Question Title * 4. Region Birmingham and West Midlands London Midlands and East Coast Northern North West & Irish Scotland Southern Wales & South West Yorkshire & North Derbyshire Question Title * 5. Branch Question Title * 6. Name of employer Question Title * 7. Approximate date of exposure to Covid-19 Please enter valid date Date Question Title * 8. Place of exposure to Covid-19 Question Title * 9. Date Covid-19 symptoms started Date / Time Date Question Title * 10. Has the member been tested for Covid-19 Yes No Question Title * 11. Positive Covid-19 test date Date / Time Date Question Title * 12. PPE provided by employer Yes No Question Title * 13. If PPE was provided what PPE was given to the member? Question Title * 14. Was the issue of a lack of PPE notified to the employer? Yes No Question Title * 15. Union rep involved (if yes, name of rep) Name of rep Question Title * 16. Have you raised a grievance (individual or collective) Yes No Question Title * 17. Have other employees tested positive for Covid-19 Yes No Question Title * 18. Have any member of your household tested positive for Covid-19 Yes No Question Title * 19. How do you travel to and from work? Question Title * 20. Do you have any underlying health conditions you are aware of ? Yes No Question Title * 21. Did you receive SSP or full pay while self isolating ? Yes No Question Title * 22. If you had sick leave did you receive SSP or full pay ? Question Title * 23. If you were off sick, was any sickness absence counted against other absences? Yes No Question Title * 24. If you received company sick pay was this in place from day one? Yes No Question Title * 25. Agreement to share information with your Union? Yes No Question Title * 26. Before submitting this form please confirm you have read and understood the privacy notice and consent to the data you have provided to be used in accordance with that notice and relevant data protection legislation. https://unionline.co.uk/privacy-policy/ Yes No Done