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Questionnaire
Step
1
of
6
– Contact Information
16%
Contact Information
Name
*
First
Last
Last 4 of SSN
*
Residential Address
*
If homeless, enter primary nighttime address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mailing Address
*
Same as residential
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Phone
*
Alternate Contact
Name
Phone
Relationship
Demographic Data
Date of Birth
*
Month
Day
Year
Age
*
Citizenship status
*
U.S. citizen
Permanent resident
Alien/Refugee lawfully admitted
None of the above
Registered for Selective Service
*
Only men born after December 31, 1959, are required to show proof of registration. A man who fails to register with Selective Service may be ineligible for the WIOA program.
Yes
No
Documented exemption
Not applicable
Veteran Information
Are you the spouse of a member of the armed forces who is on active duty?
*
Yes
No
Are you a Veteran or currently serving in the U.S. Military?
*
Yes
No
Are you within 24 months of retirement or 12 months of discharge from military service?
*
Yes
No
Enrolled in Homeless Veterans' Reintegration Program?
*
Yes
No
Employment
Employment status
*
Employed
Employed, but received notice of layoff
Not employed
Unemployment insurance
*
Neither claimant nor exhaustee
Claimant
Exhaustee
Number of Weeks Unemployed
*
Please enter a number greater than or equal to
1
.
Are you underemployed?
*
Yes
No
Current or most recent hourly rate of pay
*
Please enter a number greater than or equal to
0
.
Unemployed due to layoff or termination?
*
Yes
No
Unknown
Actual Date of Layoff/Termination
*
Month
1
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12
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Year
2024
2023
2022
2021
2020
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2016
2015
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Education
Highest school grade completed
*
Please enter a number from
0
to
12
.
High school diploma or equivalent
*
Yes
No
Highest education level completed
*
High school diploma
High school equivalency
Some college
Technical or vocational certificate
Associate’s degree
Bachelor’s degree
Master’s degree
None of the above
Current school status
*
In school
Not attending school
List school(s) and program(s) of interest
*
Public Assistance
Are you receiving, or in the past 6 months have received, the following:
(Mark “Yes” if you are a member of a family that is receiving, or in the past 6 months has received public assistance)
Temporary Assistance for Needy Families
*
Yes
No
General Assistance
*
Yes
No
Supplemental Nutrition Assistance Program
*
Yes
No
Refugee Cash Assistance
*
Yes
No
Barriers to Employment
English language learner
*
Answer “Yes” if you have limited ability in speaking, reading, writing, or understanding the English language.
Yes
No
Primary language spoken at home
*
Homeless
*
Yes
No
Involved with the criminal justice system
*
Yes
No
Other barriers to employment
*
Check all that apply to you
Transportation
No transportation
No auto insurance
Suspended driver’s license
Need vehicle repairs
Legal
Moving violations (past 3 years)
DUI offenses (past 10 years)
Criminal record (misdemeanor)
Criminal record (felony)
Probation/Parole
Pending legal issues
Family
Overdue child support payments
Lack of childcare
Lack of family support
Housing problems
Must move soon
Single parent
Financial
Financial problems
Heavy debts
Outstanding student loans
Separation/Divorce
Unable to meet basic needs (food/clothing)
Other
None of the above
Financial
Complete the following table. Include all of the individuals in your household.
Family size
*
The total number of children and adults (related by blood, marriage, or decree of court) currently living at your place of residence.
Please enter a number from
1
to
30
.
Income
*
Name
Relationship
Age
Gross income (past 6 months)
Income source(s)
Gross income is the total earnings before taxes and other deductions are subtracted.
Included as family income
Wages/Tips/Salary/Commissions
Self-employment
Railroad retirement
Strike benefits
Workers’ compensation
Training stipends
Alimony
Private pensions
Government employee pensions
Military retirement pay
State disability insurance*
Scholarships (not needs-based)
California Promise Grant – AB19
Gambling or lottery winnings
Severance pay
Terminal leave pay
Social security disability insurance*
Wages from CA Conservation Corps
Unemployment insurance
Child support payments
Social Security Old Age Insurance
*see confidential questionnaire
Excluded from family income
Needs-based public assistance
TANF, SNAP, SSI, RCA, GA
Pell Grants
Needs-based scholarships
Loans
California College Promise Grant
Veteran benefits
Income from active military duty
Capital gains
Bank withdrawals
Sale of house/car/property
Tax refunds
Gifts
Lump-sum inheritances
One-time insurance payment
Insurance compensation for injury
Non-cash benefits from employer
Medicare/Medicaid
Annualized family income
*
Confidential Health/Medical Information
Do you experience a disability?
*
Yes
No
Category of disability
*
Physical/Chronic health condition
Physical/Mobility impairment
Mental or psychiatric disability
Vision-related disability
Hearing-related disability
Learning disability
Cognitive/Intellectual disability
Prefer not to disclose
Check all that apply
In your own words, please describe your disability or the accommodations you may need
*
Section 504 Plan?
*
Yes
No
Unknown
Are you a disabled veteran?
*
Yes, disabled
Yes, special disabled (greater than 30%)
No
Have you received services from Veterans Vocational Rehabilitation?
*
Yes
No
Unknown
Have you received services from the Department of Rehabilitation?
*
Yes
No
Unknown
Do you receive Supplemental Security Income (SSI)?
*
Yes
No
Monthly SSI Income
*
Please enter a number greater than or equal to
1
.
Do you receive Social Security Disability Income (SSDI)?
*
Yes
No
Monthly SSDI Income
*
Please enter a number greater than or equal to
1
.
Are you a Ticket to Work beneficiary?
*
Yes
No
Unknown
Are you a young adult who is pregnant or parenting?
Yes
No
Who is your case manager?
*
Darlene
Jan
Jessica
Lori
Nicole (Advance at LTCC)
Sara P.
Sarah D.
Steve
Tammy
I don’t know
Release of Information
This release is a voluntary consent that allows Golden Sierra Job Training Agency to make employment inquiries, obtain records, and/or enter into discussions with other organizations.
I understand the information released will be used in order to assess, plan, and facilitate the delivery of services for my benefit. I hereby authorize my training provider to release academic records such as attendance, grade reports, and graduation status. In addition, I give permission to Golden Sierra Job Training Agency to contact my current and former employers in order to verify my employment status (i.e. start date, job title, hourly wage, and hours per week). This release will expire 3 years from the date of signature. I hereby certify that I have read and received a copy of this release.
Please type your full name to agree
*
Certification
I certify that the information provided in this questionnaire is true and correct. I am aware that this information will be used to help determine my eligibility for career and training services.
I understand eligibility for services does not constitute an entitlement to services.
Please type your full name to agree
*
Phone
This field is for validation purposes and should be left unchanged.
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