Dislocated Worker Initial Questionnaire Name * First Date Address * City * State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Postal Code Home Phone * Cell Phone Email * Date of Birth * SNN * In order that we may identify eligibility for special services and funding please answer the following: Do you have a disability? * Yes No If Yes, choose one: Temporary Permanent This information is helpful in supplying customer needs; however, you are not required to provide an answer. Have you received a written "Notice of Layoff"? Yes No If you have not received a written notice, have you received a verbal notice from your employer? Yes No Company you have been or will be laid off from: Company address: Date of layoff or expected layoff date: Ending Wage: Hourly or weekly Hourly Weekly Are you currently receiving Unemployment Insurance Benefits? Yes No Benefit end Date Number of family members living in the household Is anyone else in the household employed? Yes No Have you started a job search? Yes No Are you willing to relocate Maybe Yes No What skills do you have? What are you interests and/or hobbies? Are you currently attending? (select all that apply) High School GED Classes Alternative School College Vocational School Do you have a high school diploma? Yes No GED? Yes No Do you have any valid degrees? Yes No Certificates? Yes No Licenses? Yes No If yes, what are they? If you would like to go to school to retrain complete the following section. Course of Study Have you contacted the school of your choice and talked to a counselor? Yes No Have you been accepted into an educational program? Yes No If yes, what program: Where (School Name & Address): Does the program you plan to attend have any pre-requisites? Yes No If yes, what are the pre-requisites? Have you registered for classes? Yes No How many credit hours? Are you in default of a student loan? Yes No Are you on academic probation? Yes No Have you applied for federal financial aid? (WIA Requirement)Y Yes No Have you applied for scholarships? Yes No Do you have an award or denial letter for federal financial aid? Yes No Are you a former Workforce Investment customer? Yes No PLEASE NOTE THAT ALL INFORMATION GIVEN IS CONFIDENTIAL. reCAPTCHA If you are human, leave this field blank.