Union Member Representation Survey Form
Use this form to share your representation needs, workplace concerns, and preferred support options so the union can respond appropriately.
Member Profile
Full Name
*
First Name
Middle Name
Last Name
Union/Local Chapter Name or Number
*
Job Title / Role
Years of Membership
Preferred Contact Method
*
Email
Phone
Text Message
Mail
Representation Needs and Issues
What issues do you want representation help with?
*
Wages or pay
Scheduling or hours
Workplace safety
Discipline or disciplinary action
Contract interpretation
Grievance support
Benefits
Harassment or bullying
Other
How urgent is this issue?
*
Low
Moderate
High
Critical
Briefly describe the situation
Survey Feedback and Follow-Up
Satisfaction with current union representation
*
Very dissatisfied
1
2
3
4
5
6
7
8
9
Very satisfied
10
1 is Very dissatisfied, 10 is Very satisfied
Preferred follow-up support
*
Steward contact
Organizer contact
Legal/referral guidance
Meeting with local leadership
Informational resources
Other
Additional comments or suggestions
Submit
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