California Job Stress

On Line Submission Form

[This information will be held in the strictest confidence by us. You are NOT represented until there has been a formal agreement]

1. Contact Information(this information is required - enter "none" if you have no phone or e-mail)
Name* Phone* E-Mail*

Street Address* Zip Code*

2. What is the status of your employment?

Working regular duty Working with restrictions    Disabled    Terminated

3.  What type of injury(ies) do you have?

(check any that apply)

physical injury - single incident    

Injury Info Date of specific injury:  
Body part(s)
(hold down "Ctrl" and click to select more than one)

multiple injuries or more than one incident

Other Injury InfoDate of injury 2:
Body part(s) 2
(hold down "Ctrl" and click to select more than one)

stress on the job
injuries progressing over time - cumulative
mistreated after suffering an injury at work
previous condition aggravated at work

3. Employer

Check here if you have more than one job.  (Provide primary employer information below)
Employer Name Employer Phone Employer Fax

Employer Street Address Employer Zip Code

Date of hire:    Last day worked: (if applicable - otherwise leave blank)

4. Enter any details such as disciplinary action, threatened or actual termination and other circumstances in the box below: