Intake Forms and Return Visits, Staff

APPENDIX B
INTAKE FORMS

STUDY ELIGIBILITY CHECKLIST

This form must be completed for all customers who are eligible for intensive services.

Date:
LWIA Name: (Pre-Printed)
Center Name:

Staff Name:

Customer Name:

_____
First

M.I.

Last
MARK ONE BOX
FOR EACH

Yes

□
IS THIS CUSTOMER A VETERAN OR A COVERED SPOUSE OF A VETERAN? .............. □
HAS THIS CUSTOMER BEEN REFERRED BY AN EMPLOYER FOR AN OJT SLOT? ...... □
IS THIS CUSTOMER UNDER 18 YEARS OF AGE? .............................................................

No

□
□
□

IS THIS CUSTOMER PARTICIPATING IN:

□
An Incumbent Worker Program? ........................... [SITE SPECIFIC EXAMPLE] ......... □

– Trade Adjustment Assistance Program? .......................................................................
–

□
□

If the answer to ANY question is YES, this customer is NOT eligible for the study and should NOT
complete any other study forms OR be submitted for random assignment.
If the answer to ALL questions is NO, ask the customer to complete the consent form.

□

MARK HERE IF THE CUSTOMER HAS SIGNED THE CONSENT FORM

If the customer DID sign the consent form, this customer is eligible for the study and should complete the
study registration and contact information forms and be entered into the Random Assignment System.
If the customer did NOT sign the consent form, this customer should NOT participate in the study and
should NOT complete any other study forms OR be submitted for random assignment. They are eligible
only for core services.
Please send this Study Eligibility Checklist to Mathematica for all customers found eligible for intensive
services.

OMB Control No.: xxxx-xxxx
Expiration Date: xx/xx/20xx

Appendix B Form 1.docx

FOR COUNSELOR USE ONLY:

Study ID #: |

|

|

|

|

|

|

|

OMB Control No.: xxxx-xxxx
Expiration Date: xx/xx/20xx

STUDY REGISTRATION FORM

|

Use a black or blue ink to complete this form. Make heavy dark marks that fill the square completely.
Correct Mark

,



Incorrect Marks

.

X

.
.
Please PRINT where applicable. Enter only one number per box.
Today’s Date: |

1.

|

|/|

|

Month

2.

|/| 2 | 0 |

Day

|

| 1 | 9 |

6.

|

□ Male
2 □ Female

Year

1

Name:
7.
First Name

2a.

MI

Gender:

Last Name

Home Phone Number:

□

IF NONE, MARK HERE

(|

Maiden Name:

|

|

|) - |

|

|

|-|

|

|

|

|

Area Code

Under whose name is that phone listed?
3.

1

Address:

□ My own name

2

□ Someone else’s name (Write in):

_________________
_____________________________

|

Street

Apt. #

|

|

|

|

|

|

|

First Name

8.
___________________ |
City

|

| |

State

|

|

Cell Phone Number:

Date of Birth: |

|

|/|

|

Month

5.

|/| 1 | 9 |

Day

Year

Social Security Number:
|

|

|

|-|

|

|-|

|

|

|

|

|

|

|

|) - |

|

|

|-|

|

|

|

|

Area Code

9.

Email Address:

10.

Are you of Hispanic, Latino, or Spanish origin?

□ Yes
0 □ No
1

|

FOR COUNSELOR USE ONLY

□

IF NONE, MARK HERE

ZIP Code

(|
4.

Last Name

11.

What is your race?
MARK ONE OR MORE BOXES

□ White
□ Black or African American
3 □ American Indian or Alaska Native
4 □ Asian
5 □ Native Hawaiian or Pacific Islander
1

A. LWIA Name:

2

B. Center Name:
C. WIA Counselor’s Name:
First Name

MI

Last Name

12.
D. Customer’s Qualification status:

E. Training:

□
2□
3□
4□
1

VL
SL
SU
VU

F.

□
2□
3□
4□
1

□
2□
1

MARK ONE BOX

D

□ English
□ Spanish
3 □ Other (Write in):
1

A

2

Provider:
C.C./T.C. - 2-yr.
P
U/C - 4-yr.
O (Write in):

What is your primary spoken language?

13.

What is your marital status right now?
MARK ONE BOX

□ Married
□ Separated
3 □ Divorced
1

4

2

5

□ Widowed
□ Never married
CONTINUE ON BACK ►

2011 WIA Study Registration Form 9 20 11.docx

14.

15.

INCLUDING YOURSELF, how many people live
with you? (Please include babies, small children,
people who are not related to you, and people
who are temporarily away.)

ANSWER QUESTIONS 20-23 ABOUT YOUR CURRENT OR
MOST RECENT JOB. (If you currently have more than one job

|

20.

|

|

# OF PEOPLE LIVING WITH YOU,
INCLUDING YOU

or had more than one job recently, give answers about your
job with the most hours.)

Which of the following degrees, diplomas, or
certificates have you received?
MARK ALL THAT APPLY

□
2□
3□
4□
5□
6□
7□
8□
9□
10 □
11 □
12 □
13 □
1

What is the name of your current or former
employer?

1

□

21.

What are (or were) your main duties at this
company? PLEASE BE SPECIFIC

22.

How many hours per week do (or did) you usually
work at your main job?

None
Elementary, Middle, or Junior High diploma
High School Diploma
Adult Basic Education (ABE) certificate
General Educational Development (GED)
Vocational/Technical degree or certificate

|
23.

Associates degree (AA)
Bachelor’s degree or equivalent (BA/BS)

□
0□
17.

Other professional degree/certificate

18.

□
□
3□
4□
5□
6□
1

□
2□
3□
4□
5□
6□
0□

GO TO #24

GO TO #20

No

25.

In what month and year did your last job end?
|

|
Month

|

|•|

|

| PER

Cents

Hour
Week
Every 2 weeks
Twice per month
Year
Other (Write in): __________________________

Do you or anyone in your household currently
receive assistance from any of the following
programs?
1

Are you currently working?
Yes

|

MARK ALL THAT APPLY

Yes

□
0□
19.

24.

Have you had a job in the past five years?

1

|,|

MARK ONE BOX

Other (Write in):

No

|

(if pay varies, enter an average amount)

No

□
0□

|

Dollars

Doctor’s degree (MD, Ph.D.)

Yes

1

| HOURS PER WEEK

What was your current or most recent rate of pay,
before taxes and deductions at your main job?
$|

Master’s degree or equivalent (MA/MS)

Do you have any health problems—mental,
physical, or emotional—or substance abuse
problems that limit the kind or amount of work
or training that you can do?
1

|

Business degree/certificate

2

16.

Self-employed

| /| 2 | 0 |
Year

|

|

GO TO #20

TANF (Cash assistance)
SSI or SSDI
General Assistance
SNAP (Food Stamps)
Unemployment Compensation
Other (Write in):
IF NONE, MARK HERE

In the past, have you ever used services at this
Center or one similar to it?
1□
Yes
0□
No

Thank you for completing this form. Please return it to
your WIA counselor.

Public Burden Statement
Completing this document, which seeks to help the U.S. Department of Labor understand the effects of WIA-funded services on customers’ employment-related outcomes, is voluntary. The public reporting burden for this collection of information is estimated to average 5 minutes
per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to the Office of Policy Development
and Research, U.S. Department of Labor, Room N5641, 200 Constitution Avenue, NW, Washington, DC 20210.

CONTACT INFORMATION FORM
CONTACT INFORMATION FORM
STUDY ID #: | | | | | | | | |
Please print clearly. Use blue or black pen only

APPLICANT INFORMATION
1.

Name:

2.

Social Security Number—Last 4 Digits only:
|

First Name

Middle Initial

|

|

|

|

Last Name

CONTACT INFORMATION - RELATIVES AND FRIENDS
INSTRUCTIONS: In the space below, please provide the name, address, email address, and phone number(s) of three close
relatives or friends who do not live with you but who are likely to know how to contact you in the next year. We will only contact
these people if we cannot reach you directly. Please complete all three sections.
3.

NAME AND ADDRESS OF A CLOSE FRIEND OR RELATIVE WHO DOES NOT LIVE WITH YOU

First Name

Middle Initial

Last Name

Street Address

Apt. No.

TELEPHONE AND EMAIL:
|
City

|

|

State

RELATIONSHIP TO APPLICANT:

Home
Cell

MARK ONE BELOW

(_____) ______ - ________________
Area Code

Zip Code

(_____) ______ - ________________
Area Code

□ Parent
2 □ Grandparent
3 □ Brother/Sister
1

4.

□ Friend/Neighbor
5 □ Employer
6 □ Other ____________________________
4

Work

Number

Number

(_____) ______ - ________________
Area Code

Number

Email Address

NAME AND ADDRESS OF A CLOSE FRIEND OR RELATIVE WHO DOES NOT LIVE WITH YOU

First Name

Middle Initial

Last Name

Street Address

Apt. No.

TELEPHONE AND EMAIL:
|
City

|

|

State

RELATIONSHIP TO APPLICANT:

Home
Cell

MARK ONE BELOW

(_____) ______ - ________________
Area Code

Zip Code

(_____) ______ - ________________
Area Code

□ Parent
2 □ Grandparent
3 □ Brother/Sister
1

5.

□ Friend/Neighbor
5 □ Employer
6 □ Other ____________________________
4

Work

Number

Number

(_____) ______ - ________________
Area Code

Number

Email Address

NAME AND ADDRESS OF A CLOSE FRIEND OR RELATIVE WHO DOES NOT LIVE WITH YOU

First Name

Middle Initial

Last Name

Street Address

Apt. No.

TELEPHONE AND EMAIL:
|
City

|
State

RELATIONSHIP TO APPLICANT:

|

Home

MARK ONE BELOW

(_____) ______ - ________________
Area Code

Zip Code

Cell

(_____) ______ - ________________
Area Code

□ Parent
2 □ Grandparent
3 □ Brother/Sister
1

OMB Control No.: xxxx-xxxx
Expiration Date: xx/xx/20xx

□ Friend/Neighbor
5 □ Employer
6 □ Other ____________________________
4

Work

Number

Number

(_____) ______ - ________________
Area Code

Number

Email Address

appendix B form 3.docx