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Workplace Exposure
1.
Full name
2.
Date of birth
3.
Are you a member of the GMB Union? If yes, please provide your membership number.
4.
What was your job role at the time of exposure?
5.
Where/when did exposure happen
6.
When did you first experience symptoms
7.
Employer name
8.
Please confirm if you have had any formal medical diagnosis and if so for what ?
9.
Where/when do you consider the exposure happened ?
10.
Please explain in your own words the type of exposure (e.g. fume/dust/other)
11.
I Consent to share contact information with GMB Union
Yes
No
12.
I consent to UnionLine contacting me
Yes
No