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3663315-2476500New Jersey Intake and Initial Assessment FormUnderlined sections must be completed. Please complete additional forms if indicated..Today’s Date ______/_______/_______ SSN# ______-_____________-______Date of Birth _______/_______/_______ MM/DD/YYYYGender FORMCHECKBOX Female FORMCHECKBOX MaleLast Name First Name Middle Initial StreetCityStateZIP CodeCountyPhone #: ( ) FORMTEXT _______________Alt. Phone # ( ) FORMTEXT _______________Email: Contact Preference FORMCHECKBOX Postal FORMCHECKBOX E-mail FORMCHECKBOX Primary Phone FORMCHECKBOX Alt. Phone Ethnic Heritage FORMCHECKBOX Hispanic or Latino FORMCHECKBOX Not Hispanic or Latino FORMCHECKBOX I choose not to disclose Race FORMCHECKBOX Asian FORMCHECKBOX Alaskan/American Indian FORMCHECKBOX White FORMCHECKBOX Black/African American FORMCHECKBOX Hawaiian/Pacific Islander FORMCHECKBOX I choose not to discloseMarital and Family Status (choose all that apply) FORMCHECKBOX married FORMCHECKBOX divorced FORMCHECKBOX unmarriedHousehold FORMCHECKBOX one-parent FORMCHECKBOX two-parent FORMCHECKBOX not a family member(single) FORMCHECKBOX other (dependent, child) FORMCHECKBOX optional: pregnantSchool StatusIn-school: FORMCHECKBOX HS/secondary or Less? FORMCHECKBOX alternative FORMCHECKBOX HS/Post-secondaryNot attending school: FORMCHECKBOX HS dropout? FORMCHECKBOX HS grad/equivalent FORMCHECKBOX 16 or younger and did not attend last school year quarterEducation Level? (Choose highest level only) FORMCHECKBOX no grade?? FORMCHECKBOX ? FORMTEXT ????? Yrs completed, (1-11) no diploma FORMCHECKBOX 12th grade, no diploma FORMCHECKBOX 12th grade, HS grad FORMCHECKBOX HS equivalency FORMCHECKBOX disabled w/ Cert. IEP? Post-secondary/Vocational/Associate/High School Plus FORMCHECKBOX Post-secondary no degree FORMCHECKBOX 1 year FORMCHECKBOX 2 years FORMCHECKBOX 3 years FORMCHECKBOX Vocational Certificate FORMCHECKBOX 1 year FORMCHECKBOX 2 years FORMCHECKBOX 3 years FORMCHECKBOX Associate Degree FORMCHECKBOX 1 year FORMCHECKBOX 2 years FORMCHECKBOX 3 years FORMCHECKBOX Other Degree FORMCHECKBOX BA/BS FORMCHECKBOX Master’s FORMCHECKBOX PhD Employment Status (choose one) FORMCHECKBOX employed FORMCHECKBOX not employed FORMCHECKBOX employed but received notice of termination FORMCHECKBOX not employed and not seeking work If employed are you working (choose one) FORMCHECKBOX full-time FORMCHECKBOX part-time FORMCHECKBOX seasonal/temporary FORMCHECKBOX self-employedIf not employed and homemaker: FORMCHECKBOX Receiving support from spouse/former spouse FORMCHECKBOX Not receiving support from spouse/former spouseUS Citizen FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Permanent Resident or Exp.Date: FORMTEXT ________Alien Reg.# (if applicable): FORMTEXT ___________Individual with Disability FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Choose not to disclose [If Yes, please ask staff for Form D, which is kept confidential, and specify your type of disability: hearing; vision; mental; mobility; cognitive/I/DD; learning; chronic health]Migrant Seasonal Farmworker FORMCHECKBOX Yes FORMCHECKBOX No If Yes, choose one: FORMCHECKBOX migrant seasonal farmworker FORMCHECKBOX migrant farmworker FORMCHECKBOX migrant food process worker FORMCHECKBOX dependent of migrant seasonal farmworker Farmwork Type:? FORMCHECKBOX food processing FORMCHECKBOX production and servicesSelective Service (Males born on or after 1/1/1960 only) FORMCHECKBOX Yes FORMCHECKBOX No????????? FORMCHECKBOX Selective Service # FORMTEXT ______________ Native Language FORMCHECKBOX English FORMCHECKBOX other - specify: FORMTEXT ????? FORMTEXT ????? Military Service FORMCHECKBOX Yes - branch: FORMTEXT _____________ FORMCHECKBOX No ……………………..If Yes, use DVOP Checklist FORMCHECKBOX campaign veteran FORMCHECKBOX National Guard?? FORMCHECKBOX Reserve FORMCHECKBOX active duty? FORMCHECKBOX transitioning vet FORMCHECKBOX discharged FORMCHECKBOX retirement FORMCHECKBOX other eligible FORMCHECKBOX active service - from FORMTEXT ___________ to ? FORMTEXT ___________Service Disability FORMCHECKBOX disabled FORMCHECKBOX not disabled FORMCHECKBOX special disabled Receiving Veteran’s benefits or assistance?? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, specify: FORMTEXT _____________________________Military Spouse - Are you a: FORMCHECKBOX spouse of active duty service member FORMCHECKBOX widow of a service member FORMCHECKBOX spouse of a disabled veteran If?you are the spouse of an active duty service member, has your income been affected by your spouse’s deployment? FORMCHECKBOX Yes FORMCHECKBOX No Housing (choose one) FORMCHECKBOX foster child FORMCHECKBOX aged out of foster care FORMCHECKBOX homeless FORMCHECKBOX runaway FORMCHECKBOX own home FORMCHECKBOX rent FORMCHECKBOX choose not to disclose FORMCHECKBOX none of the above applyOffender Status - Have you been convicted of acriminal offense? FORMCHECKBOX Yes FORMCHECKBOX No??Do you believe you have any barriers to employment, including customs, practices or beliefs, not described on this form, which you wish to disclose? FORMCHECKBOX Yes FORMCHECKBOX No If Yes, please provide this information on Form D.Employment PreferencesWork Week FORMCHECKBOX full-time FORMCHECKBOX part-time FORMCHECKBOX both FORMCHECKBOX not seeking employment at this time Duration FORMCHECKBOX regular (150 Days+) FORMCHECKBOX temporary (150 days or less) FORMCHECKBOX bothMinimum Salary $____________ Per ________ Date Available to Work _____/____/_________Shift Preference Willing to work any shift? FORMCHECKBOX Yes FORMCHECKBOX No If No, which shift(s): FORMCHECKBOX 1st FORMCHECKBOX 2nd FORMCHECKBOX 3rd FORMCHECKBOX Split FORMCHECKBOX Rotating Employment Objective __________________________________________ Desired Job Title(s) 1)__________________________ 2)____________________________ 3) ______________________________4)_______________________5)____________________ Desired Employer(s) 1) _______________________________ 2) ______________________________3)_______________________Acceptable Job Locations (check one): FORMCHECKBOX 5 FORMCHECKBOX 10 FORMCHECKBOX 25 FORMCHECKBOX 50 FORMCHECKBOX 100 miles from ZIP Code ___________Work History (current/last employer) Job Title _________________________________ Employer ___________________________________Street __________________________________ City ____________________ State _____________________Start date _____/_____/________ End date _____/_____/________ Wage $____________ per_______________Reason for leaving FORMCHECKBOX lack of work/layoff FORMCHECKBOX fired FORMCHECKBOX medical/health FORMCHECKBOX quit FORMCHECKBOX retired FORMCHECKBOX strike FORMCHECKBOX still employed FORMCHECKBOX other (specify) _______________________________________________________________________Job duties _______________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________If you wish to provide additional work history, inform staff person. Additional Skills ________________________________________________________________________________________________________Professional Associations ________________________________________________________________________________________________Certificate/Special LicensesCertificate/License ________________________________ Issued by ____________________________ Date issued ____/_____/________ State _________ Country ______________________________Education/course of study ____________________________ Degree ______________________________ School __________________________ State _________ Country ______________________________Driver LicenseLicense FORMCHECKBOX No FORMCHECKBOX Yes State FORMTEXT ___________________ Type FORMCHECKBOX CDL-A FORMCHECKBOX CDL-B FORMCHECKBOX CDL-C FORMCHECKBOX Auto FORMCHECKBOX Moped Transportation FORMCHECKBOX I own a vehicle FORMCHECKBOX I have insurance I have access to: FORMCHECKBOX vehicle FORMCHECKBOX motorcycle FORMCHECKBOX bus/ rail FORMCHECKBOX none FORMCHECKBOX otherEndorsements FORMCHECKBOX passenger transport FORMCHECKBOX motorcycle FORMCHECKBOX hazardous materials FORMCHECKBOX tank vehicle FORMCHECKBOX school bus FORMCHECKBOX doubles/triples FORMCHECKBOX tank hazards FORMCHECKBOX air brakesI attest that the information provided is true and accurate. Any misrepresentation may be grounds for termination from program(s).I also understand that being eligible for services and/or training does not necessarily entitle me to service/training.Applicant Signature_________________________________ Date_________Parent/Guardian*________________________Date________Staff Signature ___________________________ Date______ Reviewed/Verified By ________________________Date________ *<18 onlyStaff use only FORMCHECKBOX WIOA Adult FORMCHECKBOX WIOA Dislocated Worker FORMCHECKBOX WDP Grant (Specify: _______________) FORMCHECKBOX National Dislocated Worker Grant FORMCHECKBOX TANF FORMCHECKBOX SNAP FORMCHECKBOX GA FORMCHECKBOX CAVPAssistance start date FORMTEXT ________ Case # FORMTEXT ____________Income Status FORMCHECKBOX 100% LLSIL FORMCHECKBOX 70%LLSIL FORMCHECKBOX Not Disclosed FORMCHECKBOX Local Priority (Specify): FORMTEXT _______________Barriers to Employment FORMCHECKBOX ELL/Lower Level Literacy FORMCHECKBOX Substantial Cultural Barriers FORMCHECKBOX Youth In/Aged out of Foster Care FORMCHECKBOX Low-Income Individual FORMCHECKBOX Displaced Homemaker FORMCHECKBOX Disability FORMCHECKBOX Indian/Alaska native/Native Hawaiian FORMCHECKBOX Homeless Individual FORMCHECKBOX Long-Term Unemployed FORMCHECKBOX Ex-Offender FORMCHECKBOX Within 2yrs of TANF exhaustion FORMCHECKBOX Eligible MSFW FORMCHECKBOX Single Parent FORMCHECKBOX Older Individual WDB (County) Code _________ FORMCHECKBOX WIOA Youth ISY FORMCHECKBOX WIOA Youth OSY FORMCHECKBOX Low-Income FORMCHECKBOX High Poverty Area FORMCHECKBOX 5% LimitationAdditional Info FORMCHECKBOX Underemployed FORMCHECKBOX Not in Labor Force FORMCHECKBOX Interested in Nontraditional Employment AOSOS ID#: FORMTEXT _______________ OSY FORMCHECKBOX Foster Youth FORMCHECKBOX Dropout FORMCHECKBOX Homeless FORMCHECKBOX Not Attended Last Q FORMCHECKBOX Offender FORMCHECKBOX Low Income AND Basic Skills Deficient FORMCHECKBOX Pregnant/parenting FORMCHECKBOX Disability FORMCHECKBOX Low Income AND youth who?Requires Add’l Assistance ISY FORMCHECKBOX Low-Income AND FORMCHECKBOX BSD FORMCHECKBOX English Language Learner FORMCHECKBOX Offender FORMCHECKBOX Homeless FORMCHECKBOX Foster Youth FORMCHECKBOX Pregnant/parenting FORMCHECKBOX Disability FORMCHECKBOX Youth who Requires Add’l Assistance Referral Source FORMCHECKBOX DVRS FORMCHECKBOX LWD FORMCHECKBOX UI FORMCHECKBOX Public Assistance Agency FORMCHECKBOX CBO/FBO FORMCHECKBOX Self FORMCHECKBOX Other Local Area FORMCHECKBOX CSBG FORMCHECKBOX Employer FORMCHECKBOX HUD FORMCHECKBOX Adult Education FORMCHECKBOX Library FORMCHECKBOX Probation FORMCHECKBOX Parole FORMCHECKBOX Public Education FORMCHECKBOX Relative/Friend FORMCHECKBOX Re-entry/Second Chance FORMCHECKBOX Displaced Homemaker Program FORMCHECKBOX Family Success Center FORMCHECKBOX MSFW Grantee 647700083820WD-175 (3/18)00WD-175 (3/18) ................
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