Preliminary Assessment

Step 1

Step 2

Step 3

Step 4

Step 5

IDENTIFYING INFORMATION

Date:*

Training or Job Search:*

Customer Name:*

CC:

Last 4 digits of Social Security Number:*

ACC:

Email:*

Phone*

Phone is:*

Cell

Home

Alternate Phone:

Alternate Phone is:

Cell

Home

Emerg. Contact:*

Emerg. Relationship:*

Emerg. Phone:*

Emerg. Email:

DOB/Age:*

Zip Code:*

Registered with Selective Service:*

Yes

SS Number:

U.S. Military Experience*

Yes

Branch:*

Branch Status*

Dishonorable

INCOME

Currently Working?*

Yes

Type*

F/T

P/T

Contract

Hours per week for current work:*

Rate per hour: $*

Title(Work):*

Company:*

City/ST:*

If not currently employed, are you receiving any other income?*

Yes

If yes, please describe:*

Are you currently collecting unemployment?*

Yes

If yes, when does your unemployment end?*

Currently in either of these programs:

SNAP

TANF

LIVING SITUATION

Current living situation:*

Homeless

Shelter

Apartment

Single family residence

Townhouse

Condo

Other:

Facing eviction?*

Yes

If yes, what is your eviction enforcement date:*

Who are you currently living with?*

Number of dependents/children under the age of 18 who live with you:*

What are their ages:*

Parent Household Status*

One parent household

Two parent household

Other

N/A

What is your plan for childcare while in training and/or when employed:*

EDUCATION

Highest level of education completed:*

< HS

GED

Some college

MBA

Name of School:

City, ST:

Degree earned:*

Do you have any certifications, licenses, or credentials?*

Yes

If yes, please list certifications:*

COMPUTER SOFTWARE KNOWLEDGE

Select all those skills which you posses*

Internet

Word

Excel

PowerPoint

Adobe InDesign

Adobe Illustrator

Other skills:

TRANSPORTATION

Do you have a valid driver’s license?*

Yes

If Yes: Class:*

Exp. Date:*

If No:*

Suspended

Revoked

Never earned one

Endorsements:*

Do you have your own reliable transportation?*

Yes

If No: Means of transportation for interviews and/or training:*

Do you have any DUIs?*

Yes

What year(s) did you receive it/them?*

POTENTIAL BARRIERS TO EMPLOYMENT (For YOUTH BARRIERS, see last page)

Can you pass a drug test today proving you are drug-free for 6 months?*

Yes

If not, why not?*

Do you have any felony convictions?*

Yes

Year(Felony convictions):*

Offense(Felony convictions):*

Do you have any misdemeanor convictions?*

Yes

Year(Misdemeanor convictions):*

Offense(Misdemeanor convictions):*

Were you incarcerated?*

Yes

If yes: Years incarcerated:*

Are you currently on parole or probation?*

Yes

If yes, when is it completed:*

Are you currently able to leave IL to work?*

Yes

Are you under a doctor’s care for medical or health concerns?*

Yes

If yes, please describe your medical or health concerns:*

Any pending surgeries, procedures, or other health obligations?*

Yes

If yes, please list pending obligations:*

EMPLOYMENT GOALS & EXPECTATIONS

Your primary employment goal:*

ITA

Job Search

Both

ITA Interest:*

How long do you expect your ITA to last?*

Why do you want to enter into this ITA?*

Three job titles you have interest in pursuing:*

List your top three (3) work-related skills:*

Desired work shift:*

1st

2nd

3rd

Weekends

Rotating

Miles willing to travel to work, one way?*

Desired salary per hour: $*

Completing job applications:*

Yes

Resume writing assistance:*

Yes

Interviewing techniques:*

Yes

Referrals to employers:*

Yes

EMPLOYMENT HISTORY

Company and City, ST:*

Title:*

Start Date:*

End Date:

Duties:*

PT/FT*

Hours per week:*

Rate of Pay:*

Were you laid off or did company close due to COVID-19?*

Reason Position Ended:

Company and City, ST:

Title:

Start Date:

End Date:

Duties:

PT/FT 2

Hours per week:

Rate of Pay:

Were you laid off or did company close due to COVID-19?

Reason Position Ended:

Company and City, ST:

Title:

Start Date:

End Date:

Duties:

PT/FT 3

Hours per week:

Rate of Pay:

Were you laid off or did company close due to COVID-19?

Reason Position Ended:

POTENTIAL YOUTH BARRIERS

Did you drop out of high school?*

Yes

Are you homeless?*

Yes

Are you a runaway?*

Yes

YOUTH NEEDING ADDITIONAL ASSISTANCE

Are you an English language learner?*

Yes

Are your family members affected by violence?*

Yes

Do you have a history of substance abuse?*

Yes

Do you have any work history?*

Yes

Does your parent or legal guardian have a history of incarceration?*

Yes

Does your parent or legal guardian have a history of substance abuse?*

Yes

Are your Reading scores below a grade level?*

Yes

Are your Math scores below a grade level?*

Yes

Do you reside in a community of high crime?*

Yes

Preliminary Assessment

IDENTIFYING INFORMATION

INCOME

LIVING SITUATION

EDUCATION

COMPUTER SOFTWARE KNOWLEDGE

TRANSPORTATION

POTENTIAL BARRIERS TO EMPLOYMENT (For YOUTH BARRIERS, see last page)

EMPLOYMENT GOALS & EXPECTATIONS

EMPLOYMENT HISTORY

POTENTIAL YOUTH BARRIERS

YOUTH NEEDING ADDITIONAL ASSISTANCE

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