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Federal Workers Job Loss Intake Form
Thank you for completing this form. Your information helps us better understand the impact on federal workers in Hampton Roads and connect you to the resources you need. Upon completing this form please visit
www.virginiaworks.com
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* Indicates required question
Name
*
First and last name
Your answer
Email
*
Your answer
Phone number
*
Your answer
Demographics (Optional)
Choose
18–24
25–34
35–44
45–54
55–64
65+
Which federal agency or department were you employed with?
Your answer
What os your current Job role/Title
Your answer
Employment Type
Choose
Full-time
Part-time
Contractor
Temporary
What is your Current Status
Choose
Furloughed
Laid Off
Reduced hours/pay
Still employed, but impacted
Other (please explain)
Date of Job Loss
MM
/
DD
/
YYYY
What kind of support do you need right now?
(Checkboxes)
Unemployment assistance
Food or housing assistance
Mental health services
Retraining or job placement
Financial counseling
Other (Please explain)
Clear selection
Are you a veteran?
Yes
No
Clear selection
Other details about your case?
Your answer
Submit
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