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Home > Businesses & Community > Workforce Development > Questionnaire

Rapid Response for Dislocated Workers

Workforce Development Services Needs Questionnaire

This questionnaire was designed to help us provide a program to meet your personal training and career needs and concerns associated with your layoff. You are not required to provide personal information, but the completion of this survey would greatly be appreciated. Individual responses are confidential.

Employee Information
First Name:      

Middle Name:   

Last Name:     
City:     State:   Zip:  
Email:     Phone (xxx-xxx-xxxx):  
Veteran Status:  
Are you the only wage earner in your house?    
Is English your primary language?     If "no," what is your primary language?  
Current Employment Information
Job Title: Company:
Number of Years:   Hourly Rate: /hr. or   Salary (numeric only): /yr.
What hourly rate do you expect in your next job?  
Where do you live? City/County of: Are you willing to relocate? 
Number of miles you are willing to drive ONE way to work? 
Please indicate the area(s) of your career interests:  

Other, please list:
Education (Highest Level Completed)  

What Job Search Assistance would best help you? (Check all that apply) 

Other, please list:
Do you believe that additional training/education would help you become more employable?     If Yes, please indicate the type(s) of training that would be beneficial. Check all that apply.  

Other, please list:  
What personal assistance or information would you consider useful? (Check all that apply).  

Please Enter the Code You See:    


Disclaimer: Rapid Response is an Equal Opportunity Program. Auxiliary Aids and Services are Available Upon Request To Individuals With Disabilities.