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Incident Report Form
Name
*
First Name
Last Name
Employer
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What city is your job in?
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Street Address
Street Address Line 2
City
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State/Province?
*
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
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New Hampshire
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Ohio
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Quebec
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Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Job Classification
e.g. Housekeeper
I witnessed violations of the following checklist items:
1. Daily room cleaning and disinfection
Stayover guest room cleaning offered only upon request
✓
Linens not changed daily
✓
High-touch surfaces are not cleaned every hour
✓
Common spaces are not cleaned every hour
✓
You were not able to clean common areas every hour because of workload
✓
Explain what you could not do:
You were not able to clean high touch areas every hour because of workload
✓
Explain what you could not do:
You were not able to complete all housekeeping tasks because of workload
✓
Explain what you could not do:
Anything else you'd like to report?
2. PPE and social distancing for ALL
Company did not give masks to employees
✓
How often were masks not available for employees?
one time the hotel ran out
some days there are masks and some days there are not
masks have never been available for employees
Company did not give masks to guests
✓
How often were masks not available for guests?
one time the hotel ran out
some days there are masks and some days there are not
masks have never been available for guests
Guests were not wearing masks
✓
How common is it that guests do not wear masks?
occasionally a guest does not wear a mask
less than half of the guests don't wear masks
more than half of the guests do not wear masks
most guests do not wear masks
Have you seen management telling guests without masks that they have to wear masks?
Yes
No
Masks that the company provided were inadequate or unsafe
✓
Explain why inadequate or unsafe:
Social distance guidelines were not posted in your work area
✓
Some guests did not maintain social distance of 6 feet from others not in their party
✓
How often does this happen?
occasionally a guest does not maintain social distance
less than half of the guests don't maintain social distance
more than half of the guests do not maintain social distance
most guests do not maintain social distance
Some guests did not maintain social distance of 6 feet from employees
✓
How often does this happen?
occasionally a guest does not maintain social distance
less than half of the guests don't maintain social distance
more than half of the guests do not maintain social distance
most guests do not maintain social distance
Anything else you'd like to report?
3. Test and screen to prevent illness
Employer did not arrange for you to be tested at reopening/return to work
✓
Employer does not ask employees daily whether experiencing any Covid-related symptoms or exposure
✓
Employer does not ask guests daily whether experiencing any Covid-related symptoms or exposure
✓
Employer does not check employees' temperatures each day
✓
Employer does not check guests' temperatures each day
✓
You were sent home for illness but were not paid sick time
✓
You have been called back to work despite having personal health concerns
✓
Anything else you'd like to report?
4. Rapid response to suspected outbreak
Do you know of any employees who were exposed to or tested positive for COVID 19?
Yes
No
Did management do anything to notify people who may have had contact with that employee?
told me
told other employees
nothing that I know of
other
Other:
Do you know of any guests who were exposed to or tested positive for COVID 19?
Yes
No
Did management do anything to notify people who may have had contact with that guest?
told me
told other employees
nothing that I know of
other
Other:
Hotel has not agreed to provide paid time so workers can isolate after exposure to COVID-19 or recover from COVID-19.
✓
Anything else you'd like to report?
5. No retaliation for workers who speak out about safety
You or your coworkers have experienced retaliation for speaking up about your safety at work
✓
Please explain what happened.
You or your coworkers have experienced retaliation for speaking up about your worksite's cleanliness
✓
Please explain what happened.
Management has not yet spoken to you about how to stay safe from COVID-19.
✓
Anything else you'd like to report?
Phone Number
-
Area Code
Phone Number
6. Other
Anything else you'd like to report?
Get ready to submit
Get ready to submit
Attach photo(s) of violations, if any.
Browse Photos
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Where in the property was this photo taken?
e.g. by front entrance, in main kitchen
What day was this photo taken?
-
Month
-
Day
Year
Date
Approximately what time was it taken?
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
30
Minutes
AM
PM
AM/PM Option
I give UNITE HERE permission to post this photo on the web.
Yes
Do you work at a UNITE HERE union workplace?
Yes
No
UNITE HERE Affiliate Union
Local 1 Chicago, Illinois
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Local 19 San Jose, Fresno-Yosemite, San Luis Obispo, Santa Barbara
Local 21 Rochester, Minnesota
Local 23
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Local 25 Washington, DC
Local 26 Boston, Massachusetts & Providence
Local 30 San Diego, California
Local 33 New Haven
Local 34 New Haven
Local 35 New Haven
Local 40 Vancouver and Vicinity, British Columbia
Local 41 Saskatchewan
Local 47 Alberta
Local 49 Sacramento
Local 54 Atlantic City
Local 57 West Virginia
Local 57 Pittsburgh, Pennsylvania
Local 74 Kansas City Chapter
Local 74 St. Louis
Local 75 Toronto, Ontario
Local 100 New York, New York
Local 150 Syracuse
Local 165 Las Vegas
Local 217 New Haven
Local 226 Las Vegas & Reno, Nevada - Culinary Workers Union
Local 261 Ottawa, Ontario - Hospitality & Service Trades Union
Local 272 Ottawa, Ontario
Local 274 Philadelphia, Pennsylvania
Local 355 Greater Miami and Ft. Lauderdale
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Local 450 Forest Park
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Local 688 Bay City, Michigan
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Local 803 Junction City
Local 878 Anchorage, Alaska
Local 2850 Oakland, California
Local 24, Detroit, Michigan and Ohio
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I don't know
Phone Number
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Email
example@example.com
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Your Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I declare that this information is true and correct.
*
Yes
Signature / Firma / Siyati / 簽名
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