Preliminary Assessment Form

WIOA Preliminary Assessment Form

Please enter your date of birth *

WIOA Preliminary Assessment Form

SECTION 1: IDENTIFYING INFORMATION

Customer Name *

Social Security Number (Last 4) *

Current Address *

Zip Code *

Phone *

Email *

Date of Birth *

Age *

Gender *

Male

Female

Non-binary

Emergency Contact Details

Name *

Relationship *

Phone *

Email *

SECTION 2: EMPLOYMENT & INCOME

U.S. Military Experience? *

Yes

Discharged *

Honorable

Dishonorable

Branch *

Army

Navy

USMC

USAF

USSF

USCG

RESERVE

Currently Employed? *

Yes

Working Type *

Full-Time

Part-Time

Contract

Internship

Company *

City/State *

Title *

Start Date *

Pay Rate $/hr *

Hours Per Week *

Benefits:

SNAP/TANF

Are you currently receiving or have you received unemployment benefits within the past 5 years? *

Yes

Unemployment Expires/Exhausted? *

Other Income

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SECTION 3: LIVING SITUATION

Are you a CHA or HCV resident? *

Yes

Current Housing *

Homeless

Shelter

Apartment

Single Family

Other

Facing Eviction? *

Yes

If yes, enforcement date *

Household size *

Other

Enter household size if not present on current selection

Number of Dependents Under 18 *

Ages *

What is your plan for childcare while in training or when employed? *

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SECTION 4: EDUCATION & SKILLS

Highest Education *

< HS

GED

MASTERS, PHD or MBA

Certifications / Licenses *

Yes

If yes, please list *

Computer Skills

Internet

Microsoft

Excel

Typing

File Management

Other Skills Not Listed

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SECTION 5: TRANSPORTATION

Valid Driver’s Licenses? *

Yes

If yes: Class *

Exp. Date *

If no *

Suspended

Never Obtained One

DUIs? *

Yes

If Yes, Year *

Reliable Transportation? *

Yes

If no, means of transportation for interviews/training? *

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SECTION 6:BARRIERS TO EMPLOYMENT

Drug Test Ready? (6 mo drug free) *

Yes

If no, why? *

Were you incarcerated? *

Yes

Years incarcerated *

Are you currently on parole or probation? *

Yes

Can you leave IL to work? *

Yes

Any misdemeanor convictions? *

Yes

Year *

Offense *

Any felony convictions? *

Yes

Year *

Offense *

Under a doctor’s care for medical or health concerns? *

Yes

If yes, please describe *

Pending surgeries, procedures, or health obligations? *

Yes

If yes, please describe *

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SECTION 7:EMPLOYMENT GOALS & EXPECTATIONS

Pathway *

Training

Job Search Only

Both

Field of Training *

Job Titles Interested in (Top 3) *

Work Related Skills (Top 3) *

Desired work shift *

1st

2nd

3rd

Weekends

Rotating

Other

Other (Please Specify) *

Travel Limit (miles one way) *

Desired Pay $/hr or Salary *

Job Assistance needed

Resume

Jon Applications

Interviews

Employer Referrals

All

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SECTION 8: EMPLOYMENT HISTORY

Do you have an Employment History? *

Yes

Company Name *

City and State *

Title *

Start Date *

End Date *

Duties *

Part Time

Full Time

Hours per week *

Rate of Pay *

Reason for Leaving *

Was this company closed due to COVID-19?

Yes

Company Name *

Title *

End Date *

Part Time

Full Time

Rate of Pay *

Was this company closed due to COVID-19?

Yes

City and State *

Start Date *

Duties *

Hours per week *

Reason for Leaving *

Company Name *

Title *

End Date *

Part Time

Full Time

Rate of Pay *

Was this company closed due to COVID-19?

Yes

City and State *

Start Date *

Duties *

Hours per week *

Reason for Leaving *

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SECTION 9: YOUTH SPECIFIC (IF APPLICABLE) AGES 18-24

Completed HS? *

Yes

If No, Why *

Homeless / Runaway? *

Yes

Additional Assistance

ESL

Substance Abuse

Violence in family

Parent Incarceration

Parent/Guardian substance abuse

Low Scores in Math or Reading

High Crime Community

Do you have any work history? *

Yes

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Form submitted successfully — we’ll be in touch shortly.

Oops! There was a problem submitting your form. Please try later.

WIOA Preliminary Assessment Form

SECTION 1: IDENTIFYING INFORMATION

Customer Name *

Social Security Number (Last 4) *

Current Address *

Zip Code *

Phone *

Email *

Date of Birth *

Age *

Gender *

Male

Female

Non-binary

Emergency Contact Details

Name *

Relationship *

Phone *

Email *

SECTION 2: EMPLOYMENT & INCOME

U.S. Military Experience? *

Yes

Discharged *

Honorable

Dishonorable

Branch *

Army

Navy

USMC

USAF

USSF

USCG

RESERVE

Currently Employed? *

Yes

Working Type *

Full-Time

Part-Time

Contract

Internship

Company *

City/State *

Title *

Start Date *

Pay Rate $/hr *

Hours Per Week *

Benefits:

SNAP/TANF

Are you currently receiving or have you received unemployment benefits within the past 5 years? *

Yes

Unemployment Expires/Exhausted? *

Other Income

Go BackGo Back

SECTION 3: LIVING SITUATION

Are you a CHA or HCV resident? *

Yes

Current Housing *

Homeless

Shelter

Apartment

Single Family

Other

Facing Eviction? *

Yes

If yes, enforcement date *

Household size *

Other

Enter household size if not present on current selection

Number of Dependents Under 18 *

Ages *

What is your plan for childcare while in training or when employed? *

Go BackGo Back

SECTION 4: EDUCATION & SKILLS

Highest Education *

< HS

GED

MASTERS, PHD or MBA

Certifications / Licenses *

Yes

If yes, please list *

Computer Skills

Internet

Microsoft

Excel

Typing

File Management

Other Skills Not Listed

Go BackGo Back

SECTION 5: TRANSPORTATION

Valid Driver’s Licenses? *

Yes

If yes: Class *

Exp. Date *

If no *

Suspended

Never Obtained One

DUIs? *

Yes

If Yes, Year *

Reliable Transportation? *

Yes

If no, means of transportation for interviews/training? *

Go BackGo Back

SECTION 6:BARRIERS TO EMPLOYMENT

Drug Test Ready? (6 mo drug free) *

Yes

If no, why? *

Were you incarcerated? *

Yes

Years incarcerated *

Are you currently on parole or probation? *

Yes

Can you leave IL to work? *

Yes

Any misdemeanor convictions? *

Yes

Year *

Offense *

Any felony convictions? *

Yes

Year *

Offense *

Under a doctor’s care for medical or health concerns? *

Yes

If yes, please describe *

Pending surgeries, procedures, or health obligations? *

Yes

If yes, please describe *

Go BackGo Back

SECTION 7:EMPLOYMENT GOALS & EXPECTATIONS

Pathway *

Training

Job Search Only

Both

Field of Training *

Job Titles Interested in (Top 3) *

Work Related Skills (Top 3) *

Desired work shift *

1st

2nd

3rd

Weekends

Rotating

Other

Other (Please Specify) *

Travel Limit (miles one way) *

Desired Pay $/hr or Salary *

Job Assistance needed

Resume

Job Applications

Interviews

Employer Referrals

All

Go BackGo Back

SECTION 8: EMPLOYMENT HISTORY

Do you have an Employment History? *

Yes

Company Name *

City and State *

Title *

Start Date *

End Date *

Duties *

Part Time

Full Time

Hours per week *

Rate of Pay *

Reason for Leaving *

Was this company closed due to COVID-19?

Yes

Company Name *

Title *

End Date *

Part Time

Full Time

Rate of Pay *

Was this company closed due to COVID-19?

Yes

City and State *

Start Date *

Duties *

Hours per week *

Reason for Leaving *

Company Name *

Title *

End Date *

Part Time

Full Time

Rate of Pay *

Was this company closed due to COVID-19?

Yes

City and State *

Start Date *

Duties *

Hours per week *

Reason for Leaving *

Go BackGo Back

Form submitted successfully — we’ll be in touch shortly.

Oops! There was a problem submitting your form. Please try later.

ONWARD AND UPWARD

WIOA Preliminary Assessment Form

WIOA Preliminary Assessment Form

SECTION 1: IDENTIFYING INFORMATION

SECTION 2: EMPLOYMENT & INCOME

SECTION 3: LIVING SITUATION

SECTION 4: EDUCATION & SKILLS

SECTION 5: TRANSPORTATION

SECTION 6:BARRIERS TO EMPLOYMENT

SECTION 7:EMPLOYMENT GOALS & EXPECTATIONS

SECTION 8: EMPLOYMENT HISTORY

SECTION 9: YOUTH SPECIFIC (IF APPLICABLE) AGES 18-24

WIOA Preliminary Assessment Form

SECTION 1: IDENTIFYING INFORMATION

SECTION 2: EMPLOYMENT & INCOME

SECTION 3: LIVING SITUATION

SECTION 4: EDUCATION & SKILLS

SECTION 5: TRANSPORTATION

SECTION 6:BARRIERS TO EMPLOYMENT

SECTION 7:EMPLOYMENT GOALS & EXPECTATIONS

SECTION 8: EMPLOYMENT HISTORY

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