Health Focus Survey

Sponsored By Alliance@IBM
 

This survey is being offered to all employees, and former employees of IBM and its contractors as a way to collect information about any adverse health effects that were suffered as a result of their exposure to chemicals and dangerous substances in their workplace.
Please fill in the spaces provided, and then print this document to your personal printer and then mail it to Alliance@IBM, 435 Main Street, Johnson City, NY 13790 or
 Fax it to Alliance@IBM at 607-797-1239.
Be careful not to fill in any text that will be pushed out of the screen area.
 

Name & Address

Phone
Email
IBM Location worked
Job Title
Dates Worked at IBM

List the chemicals or substances you worked with.

 

When (date) and Where (building)

List your health problems and treatment.

 

Do your children have health problems?

YES NO

If so what?

 

 

 

Females only:

Any history of miscarriages or children born with birth defects while you were employed at IBM?

YES NO If YES, state the history

Would you be willing to share information with a legal representative or health investigators?

YES NO

I hereby authorize Alliance@IBM to release the information, contained in this form, for informational and/or health investigation purposes.

Print Name_____________________ Signature______________________ Date______________

Comments or questions:

All the information provided to Alliance@IBM will be kept confidential and not shared with anyone under any circumstances at anytime; unless Alliance@IBM is given expressed written consent, by this document originator, to do so. All material on this site is copyright 2000-2008 Alliance at IBM/CWA Local 1701, Johnson City, NY 13790