Worker Needs Survey

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Worker Needs Survey

While completing the survey is voluntary, all affected employees are strongly encouraged to complete one because the information may be used for re-employment, retraining, research, funding, and workforce development purposes. The survey information may also prove helpful during the transition strategy development phase. All information is confidential.

Today's Date *

YYYY

Full Name (First, Middle Initial, Last) *

Name of Current Employer *

Job Title/Occupation *

Layoff Date

YYYY

Personal Phone Number (where we can contact you after the layoff) *

Personal Email Address (where we can contact you after the layoff)

Are you a Ventura County resident? *

Yes

Are you a U.S. Military Veteran or the spouse of a U.S. Military Veteran?

Yes

Clear selection

Which of the following Rapid Response sessions would you like to attend?

February 29th, 1:00pm

March 14th, 1:30pm

Clear selection

Have you filed for Unemployment?

Yes

Clear selection

Have you filed for no-cost training benefits?

Yes

Clear selection

Would you like someone to contact you to answer questions about unemployment insurance benefits?

Yes

Clear selection

Have you created an online profile on the CalJOBS website?

Yes

Clear selection

Would you like more information or someone to contact you to answer questions about no-cost training benefits?

Yes

Clear selection

Certification and Agreement

By submitting this form, I consent to the sharing of information between the WDBVC, Workforce Innovation and Opportunity Act (WIOA) program, and their partners. I understand that the information shared will be used solely in assisting me with the development of an individual employment plan.

This WIOA Title I financially assisted program or activity is an equal opportunity employer / program. Auxiliary aids and services are available upon request to individuals with disabilities.

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