Safety/Discipline Report Form

Name * First Last

Personal Email *

Non-DOE email only

UFT Member ID *

Enter 6 digits. Currently Used: 0 digits.

You can find your six-digit UFT member ID number on your UFT membership card or by logging into the UFT-Mobile app and clicking on the QR code in the upper left corner. If you are a new member and do not yet have a UFT member ID, please enter 000000.

If you belong to a UFT bargaining unit and wish to become a member, enroll now!

Title

UFT Chapter

File or EIS# *

School Code

Please use the 4-digit school code beginning with a single letter for the borough (Bronx=X, Brooklyn=K, Manhattan=M, Queens=Q, Staten Island=R) followed by 3 numbers (i.e., M594, Q011). If you do not know your 4-digit school code, please look it up on the DOE's website (it's the 4-digit code that appears in parentheses when you type in the name of your school). *

Enter 4 characters. Currently Used: 0 characters.

If your school number is only 1 or 2 digits, please enter leading zeros. (PS 1=001, PS 11=011.)

Chapter Leader First Last

If so, how many days did you miss as a result of your injury?

Provide a brief summary of the incident *

Maximum of 1000 characters. Currently Used: 0 characters.