Legal assistance for branches for work related stress personal injury advice

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1 Stre Form Lega aitance for branche for work reated tre perona injury advice WARNING: Very few work reated tre perona injury cae are uccefu a it i neceary to prove that your empoyer wa on notice that you woud uffer a recognied pychiatric ine a a reut of your empoyer behaviour. It i ao difficut to ucceed with a caim under the Protection from Harament Act a you have to have uffered a coure of extremey eriou behaviour from a coeague which woud be conidered to amount to a crimina act. The time imit that appy are outined at the end of thi form. If thee time imit are mied it i very unikey that the Tribuna/ Court wi aow your caim to proceed. ALL ection of thi form MUST be competed Section 1 to be competed by Branch Secretary Section 2 to be competed by Member Branch mut refer to the Stre Caim a guide for UNISON branche and region booket (tock no.1926) before competing the form. Section 1: to be fied in by the Branch Secretary Thi ection i to be competed fuy by the Branch Secretary. The form wi not be proceed if thi ection i not fuy competed. Name of member (peae give a the urname you have ued) UNISON region UNISON ervice group UNISON memberhip number Branch Secretary name Branch name and addre Date of joining Mae Femae Date of UNISON birth I confirm that the above named wa a fuy paid-up member of UNISON for at eat four week before the incident (the Branch Secretary ignature i confirmation that the member i entited to ega aitance). Signed Branch (Branch Secretary) Date Quetionnaire for Branch Secretary 1.1 Ha the member reported the probem to the empoyer? YES NO If o, when and what wa aid? 1.2 Ha the member intituted a grievance procedure? YES NO If o, when and with what reut? If not, why not? continue next page

2 Section 1 continued 1.3 When wa the probem referred to you? 1.4 What tep have been taken by you to reove the probem with the empoyer? 1.5 Ha a rik aement been carried out? YES NO If o, peae give detai: 1.6 What advice have you given the member o far? 1.7 Doe the member have any caim which you conider coud YES NO form the bai of a compaint to the Empoyment Tribuna? If o, peae give detai: 1.8 Ha a CASE form been competed? YES NO If o, are you aware whether the empoyment caim i being upported? 1.9 Have you advied the member of the time imit for any poibe YES NO Empoyment Tribuna caim? 1.10 Have you advied the member of any other reevant time imit YES NO (ie three year for a civi cae for a work reated perona injury tre caim)?

3 Stre Form Lega aitance for branche for work reated tre perona injury advice Thi form wi go to our awyer who wi conider whether you have a work reated tre caim or a caim under the Protection from Harament Act. They wi not conider whether you have an Empoyment Tribuna cae you houd ak your branch or regiona officer about that. Very few work reated tre perona injury cae are uccefu becaue it i neceary to prove that your empoyer wa on notice that you woud uffer a recognied pychiatric ine a a reut of your empoyer behaviour. It i ao difficut to ucceed with a caim under the Protection from Harament Act a you have to have uffered a coure of extremey eriou behaviour from a coeague which woud be conidered to amount to a crimina act. The time imit that appy are outined at the end of thi form. If thee time imit are mied it i very unikey that the Tribuna/Court wi aow your caim to proceed. Section 2: to be fied in by member Thi ection i to be competed fuy by the UNISON member. The form wi not be proceed if thi ection i not fuy competed. Member name and home addre Occupation Signed Member contact teephone number (member) Quetionnaire for UNISON member 2.1 What i your job tite? Peae decribe the type of work you do. 2.2 Peae et out in a much detai a poibe the incident which have caued your tre-reated condition and the date on which thee occurred. In repect of a caim for buying/harament peae et out detai of each incident (ue a eparate heet if neceary). continue next page

4 Section 2 continued 2.3 What ymptom have you uffered? 2.4 When did thee begin? 2.5 When did you firt connect thee ymptom to your work? 2.6 When did you firt conider that you were uffering from a pychiatric condition? 2.7 When did you firt report your probem to your empoyer? Who did you make thi report to? Peae incude any report made prior to your abence from work. If the compaint wa made in writing peae uppy a copy. 2.8 Foowing your report of probem to your empoyer peae et out detai of the tep they took? If you have been referred to Occupationa Heath peae et out detai and incude copie of any etter/report they have provided. 2.9 I there anything that you beieve your empoyer coud have done to improve your ituation? continue next page

5 Section 2 continued 2.10 Peae et out detai of any grievance which you have purued againt your empoyer and the reut. Peae incude copie of any deciion made Doe you empoyer have any poicy or practice to dea with tre at work? YES NO If o peae provide a copy Doe your empoyer provide a couneing ervice? YES NO If you have ued thi peae et out detai of the couneing provided Peae et out the firt date on which you reported the probem to your doctor and peae decribe a the treatment you have received ince that date Peae provide the date of a abence from your work due to your condition. continue next page

6 Section 2 continued 2.15 Ha your medica advior ever contacted your empoyer about the probem? YES NO If o, peae et out the detai Have any of your coeague uffered from imiar probem? YES NO If o, peae et out the detai Peae give the name and addree of any witnee who wi be prepared to upport your caim Have you uffered from any previou tre reated condition or epiode of depreion? YES NO Peae et out detai of any other factor infuencing your we-being outide of the workpace which coud caue a tre reated condition (e.g. menta heath probem, bereavement). Limitation warning for tre caim Empoyment Tribuna Caim Caim mut be received by the Empoyment Tribuna within 3 month of the effective date of termination of empoyment, Or, in the cae of ex, race or diabiity dicrimination, within 3 month from the date of the act compained of, or where the act i continuing within 3 month of the at act of dicrimination. Perona Injury Caim Court proceeding mut be commenced within 3 year of the date of an accident, or in the cae of occupationa dieae, incuding tre, within 3 year from when the member knew or ought to have known that he/he ha uffered an injury. Caim under the Protection from Harament Act 1997 Court proceeding mut be commenced within 6 year of the date on which the firt act of buying/harament occurred. Peae return competed form to: Thompon, Synergy Buiding, Harthead, Sheffied S1 2EL. Pubihed and printed by UNISON Centre, 130 Euton Road, London NW1 2AY. CU/Apri 2013/21460/tock no.1984/unp

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