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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