Delaware County Dept. of Job and Family Services

Employment & Training Information Form

Date______

Name: ______SSN#______

Address: ______

City: ______State: ______Zip: ______

Home Phone:______Alternate Phone: ______

Email address:

  1. General

How did you learn about the Dept. of Job and Family Services? ______

What type of assistance do you want? ______

______

Are you currently or have you previously used the following public services:

____ Workforce Investment Act (WIA)/ Job Training Partnership Act (JTPA)

____ Bureau of Vocational Rehabilitation (BVR)

____ Department of Job & Family Services/Dept of Human Services (DHS)

____Ohio Dept.of Job & Family Services/Ohio Bureau of Employment Services (OBES)

____ Seniors Services (Council for Older Adults)

____ Worker’s Compensation

____ Other______

Are you a Veteran? Y____ N____ If so, what branch______

Dates of Service______

Type of Training Received ______

Type of Discharge______

Are you married to or the child of a veteran? Y____ N____

  1. Employment

Are you currently employed? Y____ N____

If yes, what assistance do you need? ______

If no, please list 3 primary reasons why you feel you can not find employment:

1)______

2)______

3)______

11-24-08

Thinking of your present job skills, list 3 things that you do well:

1)______

2)______

3)______

What kind of employment are you presently looking for?

First Choice______Second Choice______

Do you feel you are qualified for your first choice? Y___ N____

Second choice? Y___ N____

What are the steps necessary for you to become employed in this field?

1)______

2)______

3)______

When you begin working, what is the lowest wage you will accept? $______

What hours do you prefer to work? ______To ______

What days do you prefer to work? Mon Tues Wed Thurs Fri Sat Sun

Are there any times you can’t work? Y ____ N _____

If yes, what days and hours? ______

Why can’t you work at these times? ______

Check your work preferences:

___ Alone___ Small/ Medium Group___ Large Group___ Lg. Company

___ Office___ Retail/Commercial___ Factory___ Small Company

Are you comfortable completing job applications?Y____ N ____

Do you have a current resume?Y____ N ____

Do you have reliable job references?Y____ N ____

Can you describe your skills to an employer?Y____ N ____

Can you conduct yourself in a job interview?Y____ N ____

Do you have enough experience to be hired presently?Y____ N ____

Are you concerned about academic skills?Y____ N ____

Do you feel your age is a barrier?Y____ N ____

Have you registered with the ODJFS (Formerly OBES)?Y____ N ____

  1. Employment History:

Begin with most recent employer and include all volunteer activities:

Name of Employer: ______Location: ______

Start Date: ______End Date: ______month/year

Beginning hourly rate ______Ending Hourly rate ______

Job title and duties/responsibilities: ______

______

Likes or dislikes of the job: ______

______

Reason for leaving job: ______

______

Name of Employer: ______Location: ______

Start Date: ______End Date: ______month/year

Beginning hourly rate ______Ending Hourly rate ______

Job title and duties/responsibilities: ______

______

Likes or dislikes of the job: ______

______

Reason for leaving job: ______

Name of Employer: ______Location: ______

Start Date: ______End Date: ______month/year

Beginning hourly rate ______Ending Hourly rate ______

Job title and duties/responsibilities: ______

______

Likes or dislikes of the job: ______

______

Reason for leaving job: ______

  1. Education and Training

High School Diploma Y _____ N ______

Highest Grade Completed ______

Last Calendar Year Attended School ______

GED Certificate Y _____ N ______

If you did not complete H.S. or obtain GED, please answer the following questions:

Why did you leave school? ______

Will you attend GED classes? ______

If no, why not? ______

Vocational Certificate Y ______N ______

Other Certificate Y ______N ______

If yes, where? ______Field of study? ______

Did you receive a degree? Y ______N ______

If yes, what type of degree did you receive: Associate____Bachelors___Master______?

Additional Education or Training completed: ______

Have you recently completed a FAFSA (Pell Grant Application)? Y _____ N ______

Are you in default on any students loans or Pell Grant Y _____ N ______

If so, how much do you owe? ______

E. Transportation

Do you have a valid driver’s license/insurance?Y _____ N _____

List any special certifications (commercial license, motorcycle license, etc.) ______

______

Do you have any major traffic violations on your record?Y _____ N _____

Do you have any points on your license?Y _____ N _____

Are you currently able to drive?Y _____ N _____

Do you have your own car?Y _____ N _____

If no, what is your primary source of transportation? ______

Is your car or source of transportation reliable? Y _____ N _____

If no, what is your back-up source of transportation? ______

Are you willing to commute or relocate?Y _____ N _____

  1. Health Issues

Health or physical limitations do not disqualify a person from participation in training or employment. However, the existence if such conditions may create special needs for you, the training situation, or the employer. Do any of the following apply to you?

Limitations on:

Standing Y _____ N _____BendingY _____ N _____

WalkingY _____ N _____Hearing Y _____ N _____

SittingY _____ N _____Vision Y _____ N _____

LiftingY _____ N _____Depth PerceptionY _____ N _____

ClimbingY _____ N _____ Color BlindnessY _____ N _____

Are you currently:

Under a doctor’s care or treatment?Y _____ N _____

Taking prescription medications on a daily basis?Y_____ N _____

Allergic to anything?Y _____ N _____

Any other health concerns? ______

Do any health concerns or items checked yes require special employment or training needs?______

Have you ever applied for SSI?Y _____ N _____

If yes, when did you apply? ______

Do you have adequate medical insurance? Y _____ N _____

Please list name , address and telephone number for the person you would like contacted in case of an emergency.

Name: ______

Address: ______

Phone #: ______

G. Miscellaneous:

Do you have adequate housingY _____ N _____

Do you have adequate food?Y _____ N _____

Do you have any legal problems? Y _____ N _____

If you have legal problems, please explain______

Have you ever been convicted of a felony?Y _____ N _____

If yes, please explain: ______

______

Is there anything happening in your life that is keeping you from getting or keeping a job? Y _____ N _____

If yes, please explain: ______

______

Do you have clothing for training, interviews, or work? Y _____ N _____

When you accept a job are your wages likely to be garnished? Y _____ N _____

Is child care needed for you to work or complete training? Y _____ N _____

Do you have back up childcare for emergencies? Y _____ N _____

Please explain childcare and back up childcare arrangements: ______

Has your childcare been reliable? Y _____ N _____

PLEASE DO NOT COMPLETE THE REST OF THIS PAGE. A STAFF MEMBER WILL COMPLETE IT WITH YOU, IF NEEDED.

  1. Assessments/Evaluations

Test (s) Administered ______Date Administered ______

Reading level ______Math Level ______

If participant is basic skills deficient, will they complete “refresher” classes? ______

Career/Vocational Assessments: Y _____ N _____

If yes, what agency/school administered the assessment? ______

If an assessment has already been completed, do you give consent for that information to be shared with others? Y ____ N ____

If yes which agency completed the assessment? ______

Please sign and date this form to authorize the release of information, if appropriate.

Signature ______Date ______