Rapid Response Local Notification Form

2. The information on this form is considered confidential and will be treated as such.

4. Name

6. Phone Number

7. Email

9. Company Name*

10. Company Address*

12. Have you missed or lost wages?*
    -- Select One --YesNo

13. Have you been told to claim your missed/lost wages?
    -- Select One --YesNo

15. Has the company you work for laid off staff?*
    -- Select One --YesNo

16. When did the layoff occur (or will occur)?

17. How many workers were laid off?

19. Company Contact Name

20. Company Contact Phone Number

22. Please describe other work-related questions or concerns.

Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field