Dislocated Worker Checklist - Kansas WorkforceOne

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					                              Dislocated Worker Referral Checklist
Client Name:                                                          SSN:

Partner Name:                                                          Date of Inquiry:

Referral to other apporpriate service providers (include date of referral):




Name and Address of Provider:

    Client may be eligible for Dislocated Worker Services in the following Category (must document)


           Category 1:       Laid-off or received a notice of lay-off from employment and is unlikely to return to
                             previous industry or occupation, and:

                                  1. Eligible for or has exhausted entitlement to unemployment compensation, or
                                  2. Not eligible for unemployment compensation, but can show attachment to the
                                     workforce.


           Category 2:       Laid-off or received a notice of lay-off from employment as a result of:

                                  1. Permanent closure or substantial lay-off at a plant, facility or enterprise, or
                                  2. Public announcement by employer of 50 or more that the facility will close
                                     within 180 days. Declaration through the media, including planned date of
                                     closure and documented verification made to the state.


           Category 3:       Was self-employed (includng employment as a farmer, rancher, or fisherman), but
                             is unemployed as a result of:

                                  1. General economic conditions in the community in which the individual resides.


           Category 4:       Displaced homemaker:

                                  1. Has been dependent on the income of another family member and is no
                                     longer dependent on the income of another family member, and
                                  2. Is unemployed or underemployed and is experiencing difficulty in obtaining
                                     or upgrading employment.


           Category 5:       Was self-employed (including employment as a farmer, rancher, or fisherman), but
                             is unemployed as a result of:

                                  1. Natural disaster(s)

				
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posted:10/21/2011
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