File No.

 

 

 

CPWR-Employment Response Report (CP-2)

New Referral                                Supplemental Referral                    Amending Referral

Section 1 – Employment to be Researched   (To be completed by DOL)  

 

 

            

 

 

 

 

 

Employer (i.e. Contractor – Subcontractor)

Facility (i.e. Oak Ridge/Y-12) 

Position Title 

 

Periods of Employment Requiring Verification

 

Period 1:                                                                  Contractual Relationship              Proof of Employment          Employment on the Premises

Period 2:                                                                  Contractual Relationship              Proof of Employment          Employment on the Premises

Period 3:                                                                  Contractual Relationship              Proof of Employment          Employment on the Premises

Period 4:                                                                  Contractual Relationship              Proof of Employment          Employment on the Premises

 

Section 2 – CPWR Research Results   (To be completed by CPWR)

 

Type of Record                                   Eligible Construction Worker       Y       N

Located

Not Located

N/A

Result/Evidence

Positive

Negative

A. Union Dispatch/Log -

 

 

 

 

 

B. Pension Fund -

 

 

 

 

 

C. Health & Welfare -

 

 

 

 

 

D. Former Worker Program - Interview Date - __________________

 

 

 

 

 

E. Facility/Site -

 

 

 

 

 

F. Other -

 

 

 

 

 

 

 

 

Additional Contacts Identified (If known):

 

 

Name

Address

Telephone

Comment

 

a

 

 

 

 

 

b

 

 

 

 

 

c

 

 

 

 

 

d

 

 

 

 

 

CPWR Contact Information (Completed by person doing CPWR records search)

 

NAME_____________________________________________________ DATE _______________________

SIGNATURE________________________________________________

TELEPHONE________________________________________________EMAIL______________________