Loudoun County, Virginia

Family Services
102 Heritage Way, N.E., Suite 103, PO Box 7400, Leesburg, VA 20177-7400
(703)777-0353 Voice (703)777-0109 FAX
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Loudoun County VIEW Program
Job Follow-Up Report
NAME:
REPORT MONTH:   REPORT YEAR:
1. Please answer the following Questions:
  A.  Are you still employed?       
      If yes:  
           Name of Employer
           Average hours per week
           Hourly rate of pay $
       If no:
           Date last worked
  B.   Are you having problems with any of the following?
     Child Care
     Transportation
     Co-workers
     Your Supervisor
     Family Life
  C.   If there is something that you would like to discuss with me, please indicate a time, date and telephone number where you may be reached or call me at the number shown at the top of the page.
Time      Date      Telephone
2.
  A.
  B.
  C.
  D.
3.
  A.
  B.
  C.
  D.
4.
Email Address: