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* 1. Contact Information

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* 2. Did you previously work for CHLB?

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* 3. What was your layoff date?

Date

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* 4. What were the dates that you were employed at Community Hospital?

Date
Date

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* 5. What department and/or unit did you work in?

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* 6. What was your job title/occupation?

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* 7. Who was your supervisor and/or manager?

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