First Name:

Last Name:

DOB:

Intake Date:

SSN:

County of Residence:

Current Credentials:

Desired Training:

TABE Scores

Name

Score

Level

Date

TABE – Language

TABE – Math

TABE – Reading

Disability that prevents from obtaining or maintaining employment

¨ Yes

¨ No

       – OOD Referral Form Completed

¨ Yes

¨ No

TAA Eligible

¨ Yes

¨ No

Veteran of the Armed Services/Eligible Spouse

¨ Yes

¨ No

PRC eligible

¨ Yes

¨ No

Number of Barriers

_______

Coordination of Services (Completed at Screening Committee)

WIOA

¨ Adult                       ¨ Dislocated                   OOD

ODJFS

¨ TAA                                 ¨ Vet/Eligible Spouse CDJFS

¨ PRC

Date Screened                                                                                               Date Re-Screened                            

MCTA                                                                                                              OOD                                                    Other

ODJFS                                                                                                              CDJFS                                                  

Notes:_____________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

General Screen 

Intake Date

Staff Office   ¨ 17-1          ¨ 17-2

Street Address

SSN

City

State  

Zip

County

First Name

MI

Mailing Street Address (If Different)

Last Name

Mailing City

Mailing State 

Mailing Zip

Mailing County

Date of Birth

Age

Gender

¨ M    ¨ F

Primary Phone

Secondary Phone

Race 

¨ American Indian/Alaskan Native

¨ Asian

¨ Black/African American  

¨ Native Hawaiian/Other Pacific Islander

¨ White

¨ Other

¨ Did Not Declare

Ethnicity

¨ Hispanic

¨ Not Hispanic or Latino

¨ Did Not Declare  

Native or Primary Language 

Additional

UI Status at Intake 

¨ Eligible Claimant Referred by NPRS

¨ Eligible Claimant Not Referred by NPRS

¨ Not a Current Claimant and Not an Exhaustee  

Education Status

¨ In School—High School or less

¨ In School—Post High School

¨ In School—Alternative School

¨ Out of School—Graduate

¨ Out of School—Dropout

Veteran 

¨ Yes     ¨ No

Spouse of a Veteran  ¨ Yes         ¨ No

Homeless

¨ Yes         ¨ No

Education Level

Program Data

Citizenship

¨  Refugee

¨  US Citizen           ¨ Other Legal Alien

¨  Registered Alien ¨ Other

Family Size  

Family Six Month Income   

Individual Six Month Income  

Dislocated Worker Details

Public Assistance Details  

Employer:

SSI                                                                                            $

City:                                                       

State:

Refugee Assistance                                                                  $

¨  Terminated or laid off

¨  Self Employed  

¨  Displaced Homemaker     

¨  Plant Closure

¨  Military Spouse  

SSDI                                                                                          $

TANF                                                                                         $

Food Stamps                                                                            $

Selective Service

       ¨ Yes              ¨ No              ¨ Exempt

UI weekly amount: $

Dislocation Wage: $

Dislocation Date:         

Tenure:                      /months

Selective Service Number   

Documented Reason for Eligibility

Adult

Dislocated Worker

Out-of-School Youth

In-School Youth

¨  Under Self-Sufficiency

——————————————–—

¨  Public Assistance Recipient

¨  Low Income

¨  Basic Skills Deficient

——————————————–—

¨  Currently Employed

¨  Terminated or laid off

¨  Self Employed  

¨  Displaced Homemaker  

¨  Plant Closure  

¨  Military Spouse  

¨ Not Attending School; and

¨ Age 16 through 24; and

One of more of the following:

¨ School Dropout

¨ Low Income/Secondary Diploma; and

¨ Basic Skills Deficient; or

¨ English Language Learner   

¨ Offender

¨ Homeless/Foster Child

¨ Pregnant/Parenting

¨ Disabled

¨ Low Income and Youth Requires 

              Additional Assistance

¨  Attending School; and

¨  Age 14 through 21; and

¨  Low Income; and

One of more of the following:

¨  Basic Skills Deficient

¨  English Language Learner

¨  Offender

¨  Homeless

¨  Pregnant/Parenting

¨  Disabled

¨  Requires Additional Assistance

Barriers Data  

¨ Disabled _______________________

          •  Complete RSC Checklist

¨ Single Parent

¨ Runaway

¨ Limited English Proficiency

¨ Behind Grade Level

¨ Basic Skills Deficient  

¨ Substance Abuse

¨ Pell Grant Recipient

¨ Subject to the Justice System

¨ Homeless

¨ Offender

¨ Foster Child

¨ Pregnant/Parenting Youth

¨ Youth Requires Additional Assistance

¨ School Dropout

¨ Lacks Transportation   

Family Information

Name

Relationship

Age

Birthday

Income Source

Amount

SELF

$

$

$

$

$

$

$

$

$

Family Size:

Total Income:

$

Applicant Work History

Company Name

Job Title

Start Date

End Date

Reason for Leaving

Hours

Wage

Emerge

ncy Contact Information

Name

Relationship

Phone

Determination of WIOA Dependent Status Checklist

Required Documentation

Yes

No

Documentation/Comments

Are you 25 or older?

¨

¨

Do you provide more then 50% of your own support*?

¨

¨

Are you married?

¨

¨

Do you have children that receive more then half of their support* from you?

¨

¨

Do you have dependents (other then your children or spouse) whom live with you and whom receive more than half of their support* from you?

¨

¨

Do you live in your own residence or in a residence without support* from  parents or guardians?

¨

¨

Are you currently serving on active duty in the U.S. armed forces for  purposes other than training?  (If you are a National Guard or Reserve enlistee, are you on active duty for other than state or training purposes?)

¨

¨

Are you a veteran for the U.S. armed forces?

¨

¨

DISCLOSURE  

NAME

RELATIONSHIP

¨

Local elected officials

¨

WDB members

¨

WDB subcommittee members

¨

WIOA executive staff and supervisors

¨

WIOA employees

¨

OhioMeansJobs center partner staff

¨

WIOA sub-recipients and/or contractors

¨

County employees

¨

N/A

Printed Name:_______________________________   Signature:______________________________    Date:____________

IF A RELATIONSHIP IS DISCLOSED

¨ There is a real or potential conflict of interest that has to be addressed with respect to who will review, 

score, and approve or deny the employer’s application.   

¨ There is not a real or potential conflict of interest that has to be addressed with respect to who will review,  score, and approve or deny the employer’s application.   

Signature:___________________________________________________________________                    Date:____________

Release of Information

       You are hereby requested and authorized to give the Mahoning and Columbiana Training Association any and all  information you may have in my files to assist with my application for employment/training, or my current employment/ training with the Mahoning and Columbiana Training Association.

      I also authorize the Mahoning and Columbiana Training Association to release to prospective employers, training institutions or social agencies any information pertaining to my application or participation in WIA activities.

Applicant Signature

Date

Parent or Guardian Signature

Date

Certification

I certify to the best of my knowledge that the information on these forms is accurate and true.  I understand that all  information is subject to verification and that falsification shall be grounds for termination and may subject the applicant to prosecution under the law.

Applicant Signature

Date

Parent or Guardian Signature

Date

Permission for Minor Child

I give my son/daughter permission to participate in the activities related to the youth programs at MCTA.  A separate  permission slip will be sent in case transportation is needed for a particular event.

Parent of Guardian Signature

Date

Recertification

I certify to the best of my knowledge that the information on these forms is accurate and true.  I understand that all  information is subject to verification and that falsification shall be grounds for termination and may subject the applicant to prosecution under the law.

Applicant Signature

Date

Parent or Guardian Signature

Date