Infrared Camera Grievance Medical Documentation Upload
Use this form to send your doctor's note or visit summary for the infrared camera safety grievance. Your records are confidential and used only for our grievance. Do not give these records to UPS management. Questions? Call or text Eric Johnson at (406) 697-6984.
Full name
*
First Name
Last Name
Mobile phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Local number
*
Job title
What are you sending?
*
Doctor's note
Visit summary
Test results
Medication list
Other
Type of provider
Eye doctor (optometrist/ophthalmologist)
Dermatologist
Primary care
Occupational medicine
Other
Date of visit
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upload your documents
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Upload a File
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Choose a file
A clear phone photo of each page is fine.
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of
Did your doctor say long periods of infrared light exposure are harmful to your condition?
Yes
No
Not yet discussed
Anything else we should know?
I agree that RAFT and the union members handling our grievance may use these records only to support the infrared camera safety grievance. I understand my records will be kept confidential and will not be given to UPS outside the official grievance process.
*
I agree
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