Dislocated Worker Survey
Document Number: DETW-17123-E
Description: The Dislocated Worker Survey is to be completed by individuals who are losing or have lost their jobs, due to a business closing or mass layoff. Information from the survey will be used for re-employment, retraining, research and economic development purposes.
Comments: The form is to be printed and manually completed by hand. The survey completion date, employer name and employer location may be entered prior to printing.
Content Contact: Gesina Mentink
Document Attachments:
DETW-17123-E (English Electronic Version - Word/128 KB)
DETW-17123-E-H (Hmong Electronic Version - Word/134 KB)
DETW-17123-E-M (Somali Electronic Version - Word/132 KB)
DETW-17123-E-S (Spanish Electronic Version - Word/353 KB)
*** If you need to access this form in an alternate format, please send an email to the Content Contact listed above.
*** Should you require the necessary software to view the above attachment, please go to the DWD Viewers Download Page. Links to each specific vendor's site have been provided for you. Thank you.