Participant Cover Sheet

Page 1

Case Information

EC Worker:

Assessment Date:

Case #:

FW Worker:

Case Close Date:

CC Worker:

Personal Information

First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

County:

Please specify:

Race:

Ethnicity:

Gender:

SSN:

Date of Birth:

Email Address:

Home Phone #:

Cell Phone #:

Immigration Status:

Immigrant - Any person lawfully in the United States who is not a U.S. citizen, U.S. national, or person admitted under a nonimmigrant category as defined by the Immigration and Nationality Act (INA) section 101(a)(15).

Refugee Status

Refugee - Status granted to an individual, prior to departure for and arrival in the United States, who has been determined by competent authority to be fleeing persecution or have a well-founded fear of persecution in their own country because of race, religion, nationality, membership in a particular social group or political opinion.

Entrance Date in U.S.

Alien #:

Disability Status:

Veteran Status:

Marital Status:

Language Spoken:

Do you speak English?:

Do you need a translator?:

What language?

Household Size

Household Income

Employment Status

Education Level

Have you or a family member/guardian ever been involved with the justice system?

The justice system is the set of courts and processes that handle legal cases, decide if laws were broken, and determine the consequences.

Are you currently without stable housing

Emergency Contact Person

First Name:

Last Name:

Relationship:

Phone #:

Pre-Employment Related

	Yes	No
Do you know how to fill out a job application?
Do you have a current/up-to-date resume?
Do you know how to present yourself at an interview?
Do you know how to job search on the internet?
Do you have a reliable phone number at which employers can contact you?
Do you have a smart phone?
Do you have a computer or tablet?
Do you have an email account?
Do you need help with setting up an email?
Do you know how to log into a virtual meeting such as Zoom or other apps?
Do you have internet service or hot spot at home?

List three jobs you are looking for:

Page 2

Work History

Are you currently working?:

Company Name:

Address:

Name of Supervisor:

Job Title:

Wage:

Start Date:

End Date:

Hours per week:

Job Description:

Reason for leaving:

Work experience from home country: list type of work, transferrable skills, interests, and abilities:

List any volunteer or unpaid work experience, if applicable:

What have you been doing since your last job, if applicable?

Resources & Referral

	Yes	No
Career Success
ESL/ABE/Financial Literacy
CJT: Listed
Job Fair
ECD (Business Development, Homeownership, Asset and Wealth Creation)
Health and Wellness (Hmong Tobacco-Free, Diabetes Prevention, Chemical Health, Mental Health & Wellness, Health Insurance Enrollment, ASCEND
Family Supports (Housing, Bridging Furniture, Food Shelves, Shelter, Legal, Energy Assistant, Weatherization Program & Emergency Assistant)
Green Card/Citizenship
Car Ownership