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 Name:*

Emerg. Relationship:*

Emerg. Phone:*

Emerg. Email:

Date of Birth*

Age:*

Zip Code:*

Current Address*

Registered with Selective Service:*

Yes

SS Number:

Gender*

Male

Female

Non-binary

U.S. Military Experience*

Yes

Branch*

Army

Navy

USMC

USAF

USSF

USCG

RESERVE

Discharge*

Honorable

Dishonorable

INCOME

Currently Working?*

Yes

Type*

F/T

P/T

Contract

Internship

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

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

Two parent

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

EDUCATION

Highest level of education completed:*

< HS

GED

MASTERS, PHD or 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

Microsoft Office

Excel

Typing

File Management

Other skills:

TRANSPORTATION

Do you have a valid driver’s license?*

Yes

If Yes: Class:*

Exp. Date:*

If No:*

Suspended

Never obtained 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

Other (Please Specify):*

Miles willing to travel to work, one way?*

Desired salary per hour: $*

Job Assistance Needed:*

Resume

Job Applications

Interviews

Employer Referrals

All

EMPLOYMENT HISTORY

Company Name*

City and State:*

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? Yes

Yes

Reason Position Ended:*

Company Name 2

City and State 2:

Title 2:

Start Date 2:

End Date 2:

Duties 2:

PT/FT 2

Hours per week 2:

Rate of Pay 2:

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

Yes

Reason Position Ended 2:

Company Name 3

City and State 3:

Title 3:

Start Date 3:

End Date 3:

Duties 3:

PT/FT 3

Hours per week 3:

Rate of Pay 3:

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

Yes

Reason Position Ended 3:

POTENTIAL YOUTH BARRIERS

Did you complete high school?*

Yes

If not, Why?*

Are you homeless/runaway?*

Yes

YOUTH NEEDING ADDITIONAL ASSISTANCE

Additional Assistance

ESL

Substance Abuse

Violence in family

Parent Incarceration

Parent/Guardian substance abuse

Low Scores in Math or Reading

High Crime Community

Do you have any work history?*

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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