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NAME OF PERSON COMPLETING THIS FORM
CUPE LOCAL NUMBER
YOUR ROLE IN YOUR LOCAL, IF ANY (E.G. SHOP STEWARD, RECORDING SECRETARY)
YOUR EMAIL ADDRESS
BEST PHONE NUMBER TO REACH YOU AT
PHONE TYPE
Cell
Work
Home
NAME OF YOUR EMPLOYER
WORKPLACE
CITY/TOWN
PROVINCE
ARE YOU THE PERSON WHO HOSTED THE WORKSHOP?
Yes
No
DATE OF WORKSHOP
HOW MANY PEOPLE TOOK PART?
DID ANYONE COME WHO WAS NOT A CUPE MEMBER? IF SO, WHO?
BASED ON YOUR DISCUSSIONS, WHAT ISSUES ARE THE MOST IMPORTANT FOR YOUR CUPE LOCAL OR COMMUNITY (LIST ALL)?
ARE THERE ANY CLIMATE CHANGE THREATS IN YOUR COMMUNITY (PLEASE PROVIDE DETAILS)?
WHAT ACTIONS DO PARTICIPANTS PLAN TO TAKE?
WHAT SUPPORT DO YOU NEED FROM CUPE TO TAKE ACTION?
DO YOU HAVE ANY OTHER FEEDBACK FOR US?
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