4 Employee work information

Job title

Employee ID number

Division name or number

Class

Employee work address (number, street, suite)

Employee status:

Full time Part time Casual Other

Date of hire

Please indicate the HOURS of work in a normal week (e.g., 9am-5pm)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Provide details if employee’s shift schedule is varied or rotational:

Are there work factors that could be impacting the employee at work?

Yes No Don't know