Follow Up Survey

This form invites you to share your employment information after completing our program. By letting us know how you’re doing, you help us highlight the success of participants like you and maintain the funding needed to keep these services available in our community.

First Name

Last Name

Contact Information Changes: (Select all that apply), I have made changes to…

Address

Telephone Number

Email Address

Street Address

city

State

Zip Code

Telephone Number

Email Address

Have you been employed at any time during the last 90 days?

Yes

Have you been actively looking for work?

Yes

Please tell us what’s preventing you from job searching so we can assist.

Would you like to be contacted to receive assistance with finding employment?

Yes

Employment

Tell us about your employment:

Company Name

Job Title

Start Date

Hours Worked Per Week

Hourly Pay

Frequency of Pay

Are you still employed with this employer?

Yes

What date did your employment end?

Since leaving this job have you been actively looking for work?

Yes

Please tell us what’s preventing you from job searching so we can assist.

Would you like to be contacted to receive assistance with finding employment?

Yes

Would you like continued support from our team to help you maintain success in your current job?

Yes

Have you received any of the following credentials since completing your training?

Please upload a copy of your credential so we can update your file.

Choose File

Signature

Sign Here

Date

An equal opportunity/employer program. Auxiliary aids and services are available upon request to individuals with disabilities.

Visit our site at careersourcepbc.com