Form Center

2. Name
3. Social Security Number
4. Date Plan Began
   Date Plan Began
6. Contact Number
7. Email Address
11. I. Education / Training
13. Did you complete high school or get a GED?

    1. Yes
    2. No
14. If not, what was the last grade you completed?
16. Have you received any post-high school education or training?

    1. Yes
    2. No
17. What training?
19. What school?
20. Did you complete?

    1. Yes
    2. No
22. What, if any, occupational license or skills certifications do you possess (ex: LPN, welding, nurse aide, cosmetology, etc.)?
24. Are you currently attending any school, training, or educational classes?

    1. Yes
    2. No
25. What training?
27. What school?
29. What, if any, training or education would you require to attain a career goal and self-sufficiency?
33. II. Skills / Experience
35. What job experience and / or occupational skills do you currently possess?
37. Do your skills/experience qualify you for employment at an adequate wage?

    1. Yes
    2. No
39. Do you have a disability or personal circumstance that will prevent you from returning to a previously held occupation?

    1. Yes
    2. No
41. If so, explain.
43. Do you have experience and skills that are not marketable in the current labor market?

    1. Yes
    2. No
45. If so, explain.
47. Do you possess good job search skills such as interviewing, completing applications, resume writing, etc.?

    1. Yes
    2. No
49. Please explain.
51. Have you encountered problems with supervisors/co-workers in the past?

    1. Yes
    2. No
53. Please explain.
55. Have personal problems unrelated to the job interfered with employment in the past?

    1. Yes
    2. No
57. Please explain.
59. Have you ever been fired?

    1. Yes
    2. No
60. If so, explain.
64. III. Employment History
    Please begin with current or most recent employer.
66. Name of Company
67. City, State
69. Job Title
70. Dates (From - To)
    Dates (From - To) Start Date

    —

    Dates (From - To) End Date
72. Reason for Leaving
74. Duties
78. Name of Company
79. City, State
81. Job Title
82. Dates (From - To)
    Dates (From - To) Start Date

    —

    Dates (From - To) End Date
84. Reason for Leaving
86. Duties
90. Name of Company
91. City, State
93. Job Title
94. Dates (From - To)
    Dates (From - To) Start Date

    —

    Dates (From - To) End Date
96. Reason for Leaving
98. Duties
102. IV. Job Goals
104. What is your occupational goal?
105. What wage will you require to be self-sufficient?
107. Name three specific personal goals that you hope to achieve as a result of working.
109. Employment Challenges

     Check all that apply

     1. Child Care
     2. Transportation
     3. Housing
     4. Ex-Offender

     1. Lack of Experience
     2. Lack of References
     3. Lack of Skills
     4. Reading

     1. Language
     2. Poor English Skills
     3. Health/Physical Limitations
     4. Mental/Emotional

     1. Legal
     2. Financial
     3. Addictions (Drug, Alcohol, Gambling etc.)
     4. Other
111. If other, explain
115. V. Occupational Preference
     Check all that apply.
117. I like working with data and information. This includes factual information, numbers, specifications, research or data based information, codes, measurements, etc.

     Examples of this type of job may include accountant, bookkeeper, credit reporter, purchaser, claim adjuster, economist, etc.

     1. Yes
     2. No
119. Comments
121. I like working with people. This includes working directly with people or helping people.

     Examples of this type of job may include social worker, teacher, nurse, policeman, waitress, receptionist, etc.

     1. Yes
     2. No
123. Comments
125. I like working with things. This includes working with machinery, office equipment, shovels, tools trucks, etc.

     Examples of this type of job may include construction trades, air conditioning and heating technicians, auto mechanics, auto body repairers, electricians, welders, truck drivers, computer repairers, machinists, general labors, etc.

     1. Yes
     2. No
129. VI. Supportive Service Needs Checklist
     Check any issues listed below for which you have a need at this time.
131. Health

     1. Get an eye exam/eye glasses
     2. See a doctor for myself
     3. See a doctor for my child
     4. Reduce my alcohol use
     5. Reduce my drug use
     6. Get my teeth fixed, go to a dentist
     7. Get personal grooming/hygiene items (makeup, toothpaste, soap, deodorant, etc.)
     8. Needs special adaptations for work skills, because of disability
132. Housing

     1. Pay past due utilities
     2. Pay rent
     3. Reduce housing costs
     4. Emergency/temporary housing
134. Case Manager Notes
135. Case Manager Notes
137. Legal

     1. Get protection from a violent person
     2. Take care of my legal problems
138. Family

     1. Learn how to control my anger
     2. Provide basic essentials for family (food, shelter, clothing)
     3. Needs child care for children
     4. Learn money management skills
140. Case Manager Notes
141. Case Manager Notes
143. Transportation

     (Need for reliable transportation)

     1. Obtain driver's license
     2. Get help with bus passes
145. Case Manager Notes
147. Please indicate any special concerns not addressed in the above list.
151. Completed by Career Center Staff Only
153. VII. Action Plan
155. Education / Training Goals
157. Employment / Career Goals
159. Support Services
161. Other Referrals
163. Workshops
164. Business Service Team

     1. Job Referral
     2. OJT
165. Assessments

     1. Skills Matching
     2. Career Explorer
     3. Career Informer
     4. Career Tips
     5. TABE
     6. SAGE
     7. WorkKeys
     8. Financial Services
167. Member's Signature
168. Date
     Date
170. Case Manager Signature
171. Date
     Date
173. R&P Case Manager Signature
174. Date
     Date
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175. Print Only

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