fax cover sheet - Norfolk Southern

FAX COVER SHEET
DATE:
_______________________________
FAX TO:
Norfolk Southern Medical Department
ATTN:
______________________________
Fax Number:
______________________________
Phone Number:
______________________________
Email:
______________________________
FROM:
Name:
________________________________________
Phone Number:
________________________________________
Fax Number:
________________________________________
______ Pages (including cover sheet)
SUBJECT: (Please check all applicable)
OFF-DUTY ILLNESS OR OFF-DUTY INJURY
WORK RELATED ILLNESS OR ON-DUTY INJURY (INCIDENT DATE:____________)
MEDICAL RECORDS
OTHER:
RE:
Employee Name:
________________________________________
Employee ID #:
________________________________________
Job Title:
________________________________________
Phone Number:
________________________________________
Email:
________________________________________
Employee’s preferred method of contact: (please check one)
Email
Phone
Either email or phone