Lane County Rapid Response Worker Survey

If you have been laid-off from work or will be, please complete the following form and someone will connect with you from WorkSource Oregon Lane.

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Today's Date: *
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Your Name: *
Your Phone Number: *
Your Zip Code: *
Your Email Address:

Preferred Contact Method:

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Obligatoire
Employer Name: *
Your Job Title:

Layoff Date - if still working, estimate last day:

 *
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Do you know if other workers at the company have been or will be affected by this layoff?

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If yes, how many workers do you estimate there are? 

Do you belong to a union?

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Do you need access to information in an additional language or require accommodations?

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If yes, please describe:

What topics would you like more information about?

Additional Comments:
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