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)
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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 |
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Positive |
Negative |
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A. Union Dispatch/Log - |
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B. Pension Fund - |
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C. Health & Welfare - |
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D. Former Worker Program - Interview Date - __________________ |
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E. Facility/Site - |
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F. Other -
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Additional Contacts Identified (If known):
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Name |
Address |
Telephone |
Comment |
a |
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b |
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c |
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d |
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CPWR Contact Information (Completed by person doing CPWR records search)
NAME_____________________________________________________ DATE _______________________
SIGNATURE________________________________________________
TELEPHONE________________________________________________EMAIL______________________