PARTICIPANT INFORMATION

First Name

Last Name

Phone *

Email *

MENTOR INFORMATION

Assigned Mentor

Date IEP Created

EMPLOYMENT GOAL

Desired Career Position

Desired Industry

Target Wage

$

Preferred Work Schedule

Full Time

Part Time

Evening Shift

Weekend Shift

Flexible

Remote

Hybrid

Other

TRANSPORTATION ASSESSMENT

Do you currently have reliable transportation?

Yes

No

Sometimes

Available Transportation Methods

Personal Vehicle (owned)

Family Transportation (owned)

Motorcycle (owned)

Bicycle (owned)

Public Transportation (bus/rail)

Ride Share

Walking

None

Other

JOB READINESS ASSESSMENT

Resume Complete?

Yes

No

Needs Updating

Interview Ready?

Yes

No

Needs Practice

Professional Email established?

Yes

No

LinkedIn Profile created?

Yes

No

Professional References available?

Yes

No

Additional Job-Readiness Needs

Resume Assistance

Interview Coaching

Professional Attire

Transportation Support

Digital Literacy

Workplace Communication

Time Management

Career Counseling

EMPLOYMENT ACTION STEPS

Employment Action Step #1

Action Step
Due Date
Status

Employment Action Step 2

Action Step
Due Date
Status

Employment Action Step #3

Action Step
Due Date
Status

EMPLOYER REFERRALS

List of provided employer referrals

1
2
3
4
5

Number of Referrals Received

INTERVIEW SCHEDULE

Employer Name

Interview Date

Interview Status

EMPLOYMENT OUTCOME

Employer

Position Obtained

Employment Start Date

Hourly Wage

$

Employment Type

Full Time

Part Time

Seasonal

Internship

Apprenticeship

RETENTION TRACKING

30-Day Retention

Employed

Not Employed

Needs Follow-Up

60-Day Retention

Employed

Not Employed

Needs Follow-Up

90-Day Retention

Employed

Not Employed

Needs Follow-Up

CASE NOTES

Employment Specialist

Mentor Notes

Barriers to Employment

1
2
3

Support Services Provided

1
2
3

FINAL ACKNOWLEDGEMENT

I understand that this Individual Employment Plan will be reviewed and updated throughout my participation in the Newark Works Youth Program.