JOBS INITIATIVE INTAKE AND INITIAL ASSESSMENT FORM

PARTICIPANT INFORMATION

Today's Date *

First Name *

Last Name *

Address *

Street Address
City
State/Province
Postal/Zip Code
County

Phone *

Alternate Phone

Email *

Preferred Contact Method: *

Gender *

Male

Female

LGBTQI

Date Of Birth *

Social Security Number *

Ethnicity *

Hispanic / Latino

Not Hispanic / Latino

I choose not to disclose

US Citizenship *

Yes

No

Permanent Resident

US Citizenship Expiration Date (if applicable)

Alien Registration # (if applicable, N/A if not)

Marital & Family Status *

Married

Divorced

Unmarried

Household *

One-parent

Two-parent

Not a family member (single)

Other (dependent, child)

School Status *

In-School: HS/Secondary or less

In-School: Alternative

In-School: HS/Post-Secondary

Not Attending: HS/Dropout

Not Attending: HS Graduate/Equivalent

Not Attending: 16 or younger & have not attended last school year quarter

Education Level (choose the highest only) *

Post-Secondary/Vocational/Associate High School Plus (please enter the # of years, if applicable) *

Post-Secondary (no degree)
Vocational Certificate
Associate Degree
Other Degree

Employment Status (choose one) *

If employed, are you working on (choose one) *

If NOT employed and homemaker, are you: *

Individual with Disability (if Yes, please ask staff for Form D, which is kept confidential, and provide the type of disability information) *

Yes

No

Choose not to disclose

Migrant Seasonal Farmworker *

Yes

No

If Yes, choose one:

migrant farmworker

migrant food process worker

migrant seasonal farmworker

dependent of migrant seasonal farmworker

Farmwork Type

Production & Services

Food Processing

Native Language *

1
2

Military Service *

Yes

No

Military Service Dates (From - To)

Military Branch

Military Service Disability

Disabled

Not Disabled

Special Disabled

Are you receiving veteran's benefits or assistance?

Yes

No

If "Yes", please specify:

Military Spouse - Are you:

Active duty service member spouse

Service member widow

Disabled veteran spouse

If active duty spouse, has your income been affected by spouse's deployment?

Yes

No

Offender Status - Have you been convicted of criminal offense? *

Yes

No

Do you feel you have any barriers to employment, including customs, practices or beliefs, not described on this form that you wish to disclose? *(if Yes, please ask staff to provide this information on Form D *

Yes

No

Do you, a friend, or any member of the family have a history of opioid use? *

Yes

No

Did you become unemployed or underemployed as a result of COVID-19? *

Yes

No

EMPLOYMENT PREFERENCES

Work Week *

Full-time

Part-time

Both

Not seeking employment at the moment

Work Duration *

Regular (150 days+)

Temporary (150 days or less)

Both

Not seeking employment at the moment

Minimum Salary per week *

$

Date Available To Work *

Employment Objective *

Desired Job Title(s) *

1
2
3

Desired Employer(s) *

1
2
3

Acceptable Job Locations: *

Enter zipcode of preferred job location/s
Upto how many miles from the above zipcode

WORK HISTORY

Current / Last Employer *

Job Title
Employer
Street Address
City, State, Zipcode
Start Date
End Date
Wage Per Hour

If "Others", please specify: *

Job duties / responsibilities *

Additional Skills

1
2
3

Additional Associations

CERTIFICATES / SPECIAL LICENSES

Certificate/License

Issued by

Issue Date

State

Country

Education-Course of Study

Degree

School

State, Country

DRIVER'S LICENSE

License

Yes

No

Licensed in which state?

TRANSPORTATION

Do you currently have reliable transportation?

Yes

No

Sometimes

ACKNOWLEDGEMENT & SIGNATURES

I attest that the information provided is true and accurate any misrepresentation may be grounds for termination from program(s). I further understand that being determined eligible for services and/or training does not necessarily entitle me to service/training

Applicant Signature *

Clear

Date Participant Signed *

Parent/Guardian's Signature *

Clear

Date Parent/Guardian Signed *

Staff Signature

Clear

Date Staff Signed