Employer-Employee Assistance Assessment

Date of incident leading to closure or loss of job?

Business/worksite address (physical location, not PO Box):

Business or Employer

Personal Information

Please select the box that best represents you: *

I am completing this form as the “Employer” I am completing this form for myself as a “Worker”

Are the affected workers union-represented?:

Yes No

If yes, provide the union and name and contact information of the union representative:

Number of affected workers:

Industry type (manufacturing, construction, business services…):

Indicate if you are a Clackamas County businesses owned by: Women, Black, Indigenous, and People of Color (BIPOC), First Nations and Tribal members, Immigrant and non-native English speakers, LGBTQ+ identified, People with Disabilities, and Veterans. Please check all that apply:

Please provide a brief description of your situation and current needs

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Employer-Employee Assistance Assessment