Completion of Needs Survey by Affected Workers

The manager may consider enclosing a "Needs Survey" in the separation packet that is given to the affected worker at the time of the layoff. The Needs Survey should be completed by the affected worker and provided to the staff of the local One Stop Center.

By completing the Needs Survey, the affected worker can focus on their immediate future needs, and begin the process of finding new employment. It will help the worker identify their current skills, knowledge and abilities, and also identify how they may possibly benefit from additional training or certification. The information contained on the Needs Survey will help the One Stop Center staff to identify the specific needs of the worker, and provide those services as quickly as possible. A sample "Needs Survey" is attached.

SAMPLE: Needs Survey

Please answer all questions in this questionnaire. The information you give will help us provide a program to meet your personal training and career needs and concerns associated with this layoff. You are not required to provide personal information, but the completion of this survey would be greatly appreciated. Individual answers will be CONFIDENTIAL.

Name _____________________________________________
(first, last)

Address _____________________________________________
(street)

_____________________________________________
(city, county, state, zip)

Phone __________________   Age ______
Male_____    Female _____

Marital Status:   Married _____    Single ______    Single Parent______

Number of Dependents:   ______ Under 18   ______ Over 18

Veteran:   _____ Yes   ______ No

Job Search Assistance

Check all areas of interest/need:

Education and Training

Check all areas of interest/need. Financial assistance may be available for the following areas:

Area of Career Interest (Please explain in detail):

Education

Please check the highest level attained:

Years of Employment with ________ - ________ Years

Future Plans

Check any that may apply. Do you plan to or have you begun to:

Concerns

Moving and Relocation

Please check all that may apply:

_____________ Willing to relocate to a different area

Number of miles you are willing to commute to a new job:

___1-10    ___11-20    ___21-30    ___31-40    ___40+

Personal Assistance and Information

If you feel that any of the following issues are of concern, please check all that may apply:

Other Concerns (please specify):

Salary

What is the minimum salary/wage you would accept in your next job?

___$5 - 7    ___$8-10    ___$11-13    ___Over $13

Please express any other concerns or comments that you feel might assist in the planning of programs and resources for you and other effected employees: