Community Action Data Entry

TECH WORKS Training Intake Checklist

Name: Date:

Please return application with all items listed below. Applications without all documents, will not be accepted Valid Driver’s License

Social Security Card for self and all household members.

Proof of Hamilton County Residence (Envelope with name printed on it, unless current address is the same as the one on photo ID).

Income Verification for the entire last 30 days for self and all household members 18 and older. (Pay stubs, social security award letter, unemployment letter, etc.)

Completed Application

These documents must be submitted before an applicant can be considered into the CDL Training Program.

As an equal opportunity employer, C-HCCAA does not discriminate in its employment decisions on the bases of race, religion, color, national origin, sex or pregnancy, age, disability, veteran or military status, genetic information or any other basis that would be in violation of any applicable federal, state or local law. Furthermore, C-HCCAA will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship for the agency.

Applicant Signature/Date Staff Signature/Date

1

Client ID # Program

CSBG INTAKE

Address:

Agency Site:

Client E-mail:

Education: Food Health Insurance: Farmer:

A. 0-8 B. 9-12 (Non-Grad) Stamps: A. Medicaid D. Self-Ins. A. Farmer

C. HS Grad/GED D. 12+ Yes B. Medicare E. None B. Migrant E. 2-4 yr. Grad College No C. Private F. Unknown C. Seasonal

Veteran: Yes

No

# In

HH

Family Type:

F. Single Par/Female Single

M. Single Par/Male Couple

Two Parent Other

Housing: Income Eligibility Period:

Own A. Weekly D. Annually

Rent B. Bi-Weekly E. 13 Weeks

Homeless C. Monthly F. 3 Months

Other G. 6 Months

Source of Income: Income Amount:

A. Employment C. Social Security E. GA G. Pension I. Other

B. Unemployment D. TANF F. SSI/SSD H. No Income J. Zero Income

K. Refused – Only used for programs that do NOT require income verification

Other Household Members

Use codes from above ONLY for information listed below

SS#

Last Name

First Name

Date of Birth

Male/Female

(M, F)

Disabled

(Y, N)

Ethnicity (B, A, NHPI,

NA, HL, W, O, MR)

Education

(A, B, C, D, E)

Veteran

(Y, N)

Health Insurance

(A, B, C, D,E, F)

Income Period:

(A, B, C, D, E, F, G)

Source (A, B, C, D, E, F, G, H, I,J,K)

Income Amount

Code#:

Initials

Date

# of Units:

Intake:

Date of Service:

Data Entry

I certify that this statement is true and correct to the best of my knowledge, and I authorize the release of any or all information necessary for verification purposes.

Applicant Signature: Date:

Staff Signature

04/08

TECH WORKS Application

Cincinnati Hamilton County Community Action Agency

PERSONAL INFORMATION

GENDER (circle one): MALE/FEMALE AGE: EMAIL:

NAME: DATE:

(LAST) (FIRST) (MIDDLE)

SS#: DATE OF BIRTH (MM/DD/YYYY):

ADDRESS: (STREET # AND NAME) (CITY) (STATE) (ZIP)

TELEPHONE #: SECONDARY TELEPHONE #: MARITAL STATUS: MARRIED SINGLE DIVORCED CIVIL UNION SINGLE PARENT RACE (please circle from the list below):

• American Indian or Alaskan Native

• Asian

• Black or African American

• White

• Native Hawaiian or Pacific Islander

• African – a national/immigrant of an African country

• Multiple

• Other

• Unknown

ETHNICITY (circle): Of Spanish/Hispanic/Latino Origin Not of Spanish/Hispanic/Latino Origin

Have you ever been convicted of a misdemeanor (this includes without limitation, pleading guilty, pleading no contest, or having a finding of guilty)? Yes No

Have you ever been convicted of a felony? (This includes without limitation, pleading guilty, pleading no contest, or having g finding of guilty)? Yes No If you checked “Yes”, please list details (where? For what? Dates?)

.

How did you hear about the program?

EDUCATIONAL BACKGROUND HIGHEST GRADE LEVEL COMPLETED:

No high school diploma or equivalent/Last grade completed High school diploma or equivalent

Some College

Associate’s Degree

Bachelor’s Degree

None

Foreign Educated – a foreign born national, educated in your home country

Do you have a disability? Yes No

Do you receive public benefits, including food stamps, subsidized housing, child care subsidies, WIC,

Medicaid, SCHIP, unemployment, etc.? Yes No

Military Service? Yes No

Selective Service registered (only if male)? Yes No

List any other any special skills you have:

Do you read or speak any foreign languages? Yes No

If yes, please list:

Computer Skills: Type WPM MS Word Excel Access PowerPoint

Employment Status: Employed Not Employed

Work History (LIST MOST RECENT EMPLOYERS FIRST)

Month/Year

Employer Name

Employer Address

Phone No.

Salary

Start

End

Reason for Leaving

From:

To:

From:

To:

Applicant Signature: Date:

COMMUNITY ACTION AGENCY WORKFORCE DEVELOPMENT POLICIES

SMOKING: In accordance with city ordinances, no smoking is permitted in public buildings.

DRUGS AND ALCOHOL: Participants shall not use or possess any controlled substance (drugs and/or alcohol). Participants shall not attend class under the influence of drugs/alcohol.

THEFT AND PROPERTY DAMAGE: Incidences of vandalism, theft or property damage will not be tolerated.

WEAPONS, VIOLENCE AND PROFANITY: No weapons of any kind are permitted.

Fighting, physical assault, profanity, or vulgar behavior will not be tolerated. FOOD AND DRINKS: To protect equipment, furniture and for sanitary reasons, eating and drinking are not permitted in the classroom.

ELECTRONIC DEVICES: MP3 plyers, Radios, CD players, tape players, electronic fames, pagers and cellular phones will not be permitted in the classroom.

SEXUAL HARASSMENT: Participants who feel they have been sexually harassed or intimidated should report such actions immediately to the instructor. Sexual harassment is defined as “any unwelcomed sexual advances or requests for sexual favors”.

SLEEPING: Sleeping is not permitted

DRESS: Appropriate dress is required at all times. Halters, tube tops, short shorts, and visible under-garments, etc. will not be permitted. Clothing with inappropriate slogans, expressions, and/or pictures will not be permitted.

COMPUTER USAGE: The primary use of the computers is for education/ employment activities. Personal use of the computer is not permitted. Access to inappropriate sites is prohibited and may lead to disciplinary action.

Violation of these policies may result in termination from the program and notification of proper authorities when warranted.

I have read the Workforce Development Policies and full understand and accept the program requirements.

PARTICIPANT SIGNATURE DATE

CHCCAA Employment and Development Agreement

I agree to inform the CAA’s TECH Partnership Program upon obtaining employment.

I give permission to the CAA TECH Partnership Program to verify my employment status, include salary and benefit information, through direct access with my employer. Direct access incudes phone calls, fax, email regular mail and/or any other employment verification systems.

Name: Date:

Signature:

Publicity Consent Form

Name

Street Address

City State Zip Code

Daytime Phone

I hereby grant permission to the Cincinnati-Hamilton County Community Action Agency (CAA) to use my name, story, photograph, voice recording or any other electronic image or representation regarding my experience with CAA’s programs and services strictly and exclusively for publicity or promotional purposes. I agree that all above mentioned images taken by any CAA personnel will become the property of the agency. CAA shall be the exclusive copyright owner of said works and related trademarks, service marks and trade names. CAA shall have the exclusive right to reproduce, broadcast, perform and otherwise publish and use said works, prepare derivative works of said works and authorize others to do any of the foregoing; furthermore, CAA shall have all other rights granted to an owner of a copyright under the Copyright Act of 1976, as amended from time to time. I further agree that I have no copyright ownership or other right, title or interest whatsoever in the publications and/or products created by CAA.

Signature Date Request to withhold name:

I hereby grant permission for CAA to use my story, photograph, voice recording or any other electronic image or representation regarding my experience with CAA’s programs and services, but I request that my story and experience be assigned a pseudonym – a fake name.

Signature Date

Program Assessment

Assessment – Needs, Strengths and Experience

Name: Date:

1. What are your expectations for this Career Readiness Program: ?

2. Do you have any Medical issues that affect your job search or the type of work you can perform? YES NO

If yes, please explain: .

3. Do you use alcohol or drugs? YES NO

4. Could you pass a drug test? YES NO

5. Do you currently have any pending legal issues or child support issues? YES NO

If yes, please describe: .

6. Do you need assistance with any of the following?

Childcare: YES NO Clothing: YES NO Housing: YES NO

Legal Advice: YES NO

7. Please list examples of your previous employment experience:

a. .

b. .

1. What are your top two future employment choices?

a. .

b. .

1. Either from life experience or employment experience, what transferable skills do you possess?

a. .

b. .

c. .

1. What shift are you able to work? .

2. Do you have a Driver’s license? YES NO

3. Do you have your own means of transportation? YES NO

4. Is there a geographic location in which you need to work?

Conviction History

Misdemeanor/Felony

(circle one)

Date of Offense

Type of Offense/ Details

Misdemeanor/Felony

Misdemeanor/Felony

Misdemeanor/Felony

Misdemeanor/Felony

Misdemeanor/Felony

How did you hear about Cincinnati Hamilton County Community Action Agency?

Mark D. Lawson

President/CEO

Chandra Mathews-Smith

Board Chair

CSBG PROGRAMS

[TECH WORKS]

Income Self-Declaration Worksheet

Name: Date:

Address: Phone:

Street City Zip

If you are receiving assistance with paying your bills and / or expenses from a non-household member, please list their name, address and phone number below. If one or more person is paying expenses, have him/her submit a separate statement.

Name Address Phone

1.

2.

3. Please state the amount of your monthly expenses. (Write N/A to any that do not apply)

Bill

Monthly Amount

Gift / Loan/ Paid Directly to creditor

Rent / Mortgage / Taxes

$

Given to you

Paid Directly to Creditor

Food

$

Given to you

Paid Directly to Creditor

Gas / Electric

$

Given to you

Paid Directly to Creditor

Water

$

Given to you

Paid Directly to Creditor

Phone

$

Given to you

Paid Directly to Creditor

Car Payment / Insurance

$

Given to you

Paid Directly to Creditor

Cable / Internet

$

Given to you

Paid Directly to Creditor

Personal Expenses

$

Given to you

Paid Directly to Creditor

Bulk Fuel

$

Given to you

Paid Directly to Creditor

Other Expenses

$

Given to you

Paid Directly to Creditor

Does your household receive any of the following?

Food Stamps Yes Amount $ No

Rental Assistance such as subsidized housing Yes Amount $ No

Utility Allowance Yes Amount $ No

Briefly explain how you maintained your household bills and expenses within the past 90 days.

I understand that by signing this form, I authorize the Ohio Department of Development, Office of Community Services or its designated representatives, access to public assistance, social security, employment information or other records needed to verify any statements I have made.

I declare under penalty of perjury that the information submitted on this worksheet is true and correct.

Customer Signature: Date:

Staff Signature: Date:

APPLICANT STATEMENT

1. My signature authorizes Cincinnati-Hamilton County Community Action Agency (C-HCCAA) or its authorized agents to conduct a thorough investigation of all statements, written and oral, made by me during the employment application process, including without limitation, information concerning my employment positions, law enforcement record, driving record, and educational background. I hereby authorize all persons, companies or other entities connected with any such informational request, including without limitation, current or prior employers and law enforcement agencies to provide any and all information they may have regarding me or my employment. I release and agree to indemnify C-HCCAA, its authorized agents, and its employees, and all other persons, companies, and other entities from any and all liability arising out of such investigation, including without limitation any liability for furnishing information or for taking any action based on the information provided.

2. I hereby certify that all responses set forth during my employment application process are true and complete. I understand and agree that any falsification, misrepresentation, or omission either on the employment application form or in my responses to questions asked during the interviewing or examination process may disqualify me from further consideration for employment, or if employed by C-HCCAA, will subject me to immediate termination, whenever the falsification or omission is discovered. In this regard, where an item is left blank on the employment application, it is because there is no information within its scope.

3. I understand that a drug and/or alcohol screen may be required before and during my employment. In addition, I authorize a medical examination, including a drug and/or alcohol screen, by an examiner selected by C-HCCAA if I am made a contingent offer of employment. I release and agree to indemnify C-HCCAA, its authorized agents, and its employees, and all other persons, companies, and other entities from any and all liability arising out of any medical examination or drug/alcohol screen or for the taking of any action based on the results of any medical examination or drug/alcohol screen.

4. I agree and consent that C-HCCAA may inspect any C-HCCAA property at any time and for any reason, without notice. This property includes, without limitation, work stations, computers, offices, desks, lockers, voice mail, and filing cabinets. Additionally, I agree and consent that any personal items I bring onto CHCCAA’s premises are subject to inspection at any time and for any reason, without prior notice.

5. I certify that I am a citizen of the United States, or, if not, I can provide required documentation permitting me to work in the United States.

6. In consideration of C-HCCAA’s review of my application, I agree that any claim or lawsuit arising out of my application for employment with, my employment with or subsequent separation from C-HCCAA or any of its divisions must be filed no more than one hundred and eighty (180) calendar days after the date the employment action that is the subject of the claim or lawsuit. While I understand that the statute of limitations for claims or actions arising out of an employment action may be longer than one hundred and eighty (180) calendar days, I agree to be bound by the one hundred and eighty (180) calendar day period of limitations set forth herein, and I waive any STATUTE OF LIMITATIONS TO THE CONTRARY. Should a court determine in some future lawsuit that this provision allows an unreasonably short period of time to commence a lawsuit, the court shall enforce this provision as far as possible and shall declare the lawsuit barred unless it was brought within the minimum reasonable time within which the suit should have been commenced.

7. I understand and agree if I am employed by C-HCCAA, my employment is at-will so that I may terminate my employment at any time and for any or no reason. Likewise, C-HCCAA can terminate my employment at any time and for any or no reason. I also understand and agree that nothing contained in C-HCCAA’s employment application or in the granting or conducting of an interview or anything set forth in any oral or written statement, communication, or policy now or in the future constitutes or creates or is intended to constitute or to create a contract or promise between me and C-HCCAA for employment, hours of work, or for the providing of benefits. Moreover, I acknowledge that C-HCCAA reserves the right to modify, revoke, suspend, terminate or change any or all of its plans, policies, or procedures at any time, without prior notice. No promises or guarantees regarding employment, hours of work, or for the providing of benefits have been made to me. I further understand and agree that no such promise or guarantee is binding on C-HCCAA unless it is in writing signed by me and the President/CEO of C-HCCAA and that document states that the employment relationship is not “at-will” and details the specific promise or guarantee.

Applicant’s Signature Date

9

Contact this candidate