Self Assessment DHS 7823 1/09 - Oregon DHS Applications …



|[pic] |Self Assessment Tool |

|Self Sufficiency Programs |(use with the DHS 7823A) |

|Temporary Assistance for Needy Families | |

|Name (First, Last, MI): |Date : |DHS use only |

|      |   -    -      |Case number:       |

|Section A — My family |

|1. What are the ages of your children? |      |

| Do your children attend school? Yes No If yes, where?       |

|2. How are your children doing in school? (academically and socially)       |

|3. Check which of the following describes your household: |

|Two parent Single parent Teen parent |

|4. Who would encourage your working?       |

|5. Who would discourage your working?       |

|6. What help do you think you could get from family and friends?       |

|Section B — My education |

|Check highest grade completed: |

|1 2 3 4 5 6 7 8 9 10 11 12 13 14 16+ |

| |

|Do you have a high school diploma? Yes No |

| |

|Do you have a GED? Yes No |

|What other schooling or training have you had since high school? (Check all that apply.) |

|Community College Job Corps Four year college Trade school |

| Military Other: |      |

| |

|5. Are you currently in school or training? Yes No |

| |

|6. Do you have any certificates of training or occupational license? (For example C.N.A., |

|cosmetologist, contractor) Yes No |

| If yes, what kind(s): |      |

| When did you receive the certificate or license? (month/year) |      |

|Section C— My work experience |

|What jobs have you done? (include odd jobs you may have done from time to time to make |

|extra money) |

|      |

|2. Describe what you did in those job experiences? |

|      |

|3. What reasons did you have for leaving those jobs? (list any you can think of about the jobs |

|you mentioned) |

|      |

|4. What was the length of your longest job? |

|      |

|5. What would your employers say about you if I asked for a reference? (list anything you can think of from any of the employers from your job experiences) |

|      |

|6. What work have you done without pay? Example: helping at your church, kids’ school or in your |

|community. Or to help family, friends or others? |

|      |

|7. What did you like most about working? |

|      |

|8. What did you not like about working? |

|      |

|Section D — Things I don’t like |

|What I don’t like about my life. Check all that apply to your life now. |

| where I live | having others controlling my life |

| what I can buy for myself | depending on friends and relatives |

| what I can buy for my children | where I have to shop |

| the car I have now | not being able to go on a nice vacation |

| not having a car | not being able to help the people who have helped me |

| having to use public assistance | |

| people looking down on me | other:       |

|Notes:       |

|Section E — Things I would like |

|What I would like to have in my life. Check all that apply to your life now. |

| better place to live | nice furniture |

| buy things for myself | take a trip by myself |

| buy things for my children | take my children on a vacation |

| get a car | help some of the people who helped me |

| spend my money the way I want to | other: |      |

| more independence from relatives and friends | other:       |

|Notes:       |

|Section F — Help I may need |

|What help do you need? What can we do to help you work toward your goals? |

|(Check all that apply.) |

| child care assistance | help with drug or alcohol abuse |

| transportation assistance | counseling or help with stress management |

| how to look for work | help to leave an abusive situation |

| education and/or training | help with stable housing |

| getting child support | encouragement |

| help with relationship skills | help with my children’s problems |

| other:       | other:       |

|Notes:       |

|Section G — You are working or have worked with: |

|Are you or anyone in your family working with other agencies now or in the past? Yes No |

|If yes, check all that apply: |

|Agency |Past |Present |Agency |Past |Present |

| Corrections/Parole | | | One-stop or Career Centers, | | |

|and Probation | | |Employment Dept., WIA | | |

| Division of Child Support | | | Senior and/or | | |

| | | |Disability Services | | |

| Domestic Violence Services | | | Social Security (SSI/SSD/SSB) | | |

| Drug or Alcohol Services | | | Support groups | | |

| Family Support and Connections | | | Vocational Rehabilitation | | |

| Head-Start or Healthy-Start | | | Women, Infants and Children (WIC) | | |

| Juvenile courts | | | Worker’s Compensation (SAIF) | | |

| Legal Aid | | | Other:       | | |

|The Department of Human Services (DHS) will not discriminate against anyone. This means DHS will help all who qualify. DHS will not deny help to anyone based on |

|age, race, color, national origin, sex, sexual orientation, religion, political beliefs or disability. You can file a complaint if you think DHS discriminated |

|against you for any of these reasons. |

|“Equal Opportunity is the Law” |

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