Local Union 825 Discharge Form

Operator Discharge Form

Enter company information and date of incident:

Company Name:

Company Representative:

Date of Accident/Discharge:

Enter operator's information and employment dates:

Operator's Full Name:

Project Location:

Employment Start Date:

Employment End Date:

Describe equipment and type of work:

Specific piece of equipment in question:

Type of work being performed (i.e. finish grading, paving, loading trucks, etc.):

Describe reason for discharge and any other relevant information:

Specific reason for discharge:

Was the operator advised as to the reason for dismissal?:

Name of person discharging operator:

Additional Information/Comments:

Cancel