Pleaseanswerallofthefollowingquestionsascompletelyaspossible.Theinformationyouprovideisconfidentialandwillbeused to help us help you develop your Employment First participationplan.

Name / SSN:(Last4) / CaseNumber:
1B / Date ofBirth
Address / Phone(message)
Mailing Address (If different fromabove) / EmailAddress
PERSONALINFORMATION
Please print & complete the sectionsbelow. / STAFF USE ONLY
Verification Received/Resource Provided
EMPLOYMENT
Are you currently employed? ___Yes ___No
If YES, please circle one:
Full / Part-time | Temporary | Day Labor
Start Date: ______
Kind ofWork: ______
# Hrs Per Week: ______
HourlyWage:______
CompanyName: ______
PhoneNumber: ______/ If NO, please list the month and year when you last worked:
Month: ______
Year: ______
Are you looking for work currently?
___Yes ___No
Are you on a temporary layoff and expect to return to work within 60 days? ___Yes ___No
BENEFITS
Please circle any of the following benefits you are currently applying for orreceiving:
UI (UnemploymentInsurance)TANF (CO Works or FamilyPreservation)
AND(Aid to the NeedyDisabled)SSI (Supplemental SecurityIncome)
CRSP (Colorado RefugeeServices)Veterans Disability
FA (FoodAssistance) Medicaid
CARE OF OTHERS
Are you responsible for the care of a dependent childinyourhousehold? ___Yes ___No
If yes, what age is the child? ______/ Is childcareneeded?
Are you responsible for the full-time care of an incapacitatedperson? ____Yes ____No / Is careneeded throughout the day?
EDUCATION
Highest grade you completed: ______
Are you interested in continuing or finishing your education? ___Yes ___No
Are you currently in school? ___Yes ___No
• If yes, what is the name of the school or program: ______
• When did you start (date)?______When will you finish (date)?______
• What days and hours are you in school?
• Besides school, are there trainings you have completed? If yes, please list:
______
REHABILITATION
Are youcurrentlyenrolledin a VocationalRehabilitationprogram? ___Yes ___No
MILITARY
Have you ever been in the military? ___Yes ___No / Active Military Status?
SAFETY
Do you have a stable place to stay at night? ___Yes ___No
HEALTH
Do you have any physical conditions that limit your ability to work? ___Yes __No
Are you pregnant? Yes___ (expected delivery date______) ___No
Do you have any medical needs that are not being treated? ___Yes ___No
Do you have any mental conditions that limit your ability to work? ___Yes ___No
Are you currently takingmedication that would affect your ability to look for work? __Yes ___No
IDENTIFICATION
Do youhave a validI.D.? ___Yes ___No
CircleType:Driver’sLicenseStateIDOther
TRANSPORTATION
How will you get towork or class?(Circle all that apply)
MyCar | Bus | Walk | Bike | Friends | BorrowedVehicle | Don’tKnow
WORK
• Are youregisteredwithConnecting Colorado or working with the
WORKFORCECENTER? ___Yes ___No
• Are youworkingwithanotheragency to findemployment? ___Yes ___No
If yes, please provide:
NameofAgency ______
Type ofAssistance______
ContactPerson ______
LEGAL
We want to do the best we can to place you at an appropriate work site if your participation depends on that, andto identify possible resources that may help you that pertains to the following information:
• Do you have any legal or background issues (including felonies or misdemeanors)that you would need to disclose to an employer? ___Yes ___No
• Are you on probation or parole: ___Yes ___No / Note relevant dates to assist in work site placement and possible
community resources:
DOMESTIC VIOLENCE
Are you currently in a domestic violence program that wouldpreventyou from looking
forwork? ___Yes ___No
TREATMENT
Are youcurrently indrug or alcoholtreatment? Yes ___No
BARRIERS
15. Do you have any physical conditions that limit your ability to work? ___Yes ___No
Are you pregnant? Yes___ (expected deliverydate______) ___No
Do you have any medical needs that are not beingtreated? ___Yes ___No
Do you have any mental conditions that limit your ability to work? ___Yes ___No
Are you currently taking medication that would affectyour ability to look forwork?
__Yes ___No
*Haveyou applied forMedicaid?___Yes___No
What do you think is your biggest barrier toemployment?
GOALS
What employment or career goals do you have? We want to help.