City of Alexandria Upskilling Program Screening Form

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* 1. Understanding of Participation Requirements
The purpose of the City of Alexandria Upskilling Program is to assist participants in gaining the knowledge, skills, and work experience needed to obtain a higher paying job.

I understand that there are eligibility requirements and that if I participate in the Upskilling Program, I will communicate regularly with program staff who will assist me in meeting my employment goals. If yes, please continue to complete the form.

Yes

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* 2. Today's Date (MM/DD/YYYY)

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* 3. Full Name

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* 4. Contact Information

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 5. Best way to contact you

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* 6. Date of Birth MM/DD/YYYY

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* 7. Are you eligible/authorized to work in the United States?

Yes

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* 8. Are you a veteran of the United States military?

Yes

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* 9. What is the primary language you speak at home?

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* 10. Do you need English translation assistance?

Yes

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* 11. Do you need English as a Second Language (ESL) classes?

Yes

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* 12. “Federal law requires employers and American Job Centers to provide reasonable accommodation to qualified individuals with disabilities. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment”.

Do you require a reasonable accommodation to apply for a job or to perform your job?

Yes (Please specify below.)

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* 13. Do you receive any of the following benefits/public assistance? (If Yes, please select all that apply. If No, please select N/A.):

N/A

Medicare

Medicaid

SSI (Supplemental Security Income)

SSDI (Social Security Disability Insurance)

TANF (Temporary Assistance for Needy Families)

SNAP (Supplemental Nutrition Assistance Program)

SNAPET (Supplemental Nutrition Assistance Program Employment and Training)

WIOA (Workforce Innovation & Opportunity Act)

VIEW (Virginia Initiative for Education and Work)

Public Housing

Other (please specify)

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* 14. Are you currently employed?

Yes

No (Please enter your last day of work below.)

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* 15. Are you receiving Unemployment Insurance (UI) benefits?

Yes (Please enter the date of your termination letter below.)

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* 16. Have you received Unemployment Insurance (UI) benefits in the past?

Yes (Please enter dates you received UI benefits below.)

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* 17. What is your highest level of education?

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* 18. Are you pregnant or parenting?

Yes

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* 19. Have you ever been in Foster Care?

Yes

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* 20. Are you experiencing homelessness?

Yes

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* 21. How many people live in your household?

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* 22. What is your approximate annual household income?

Less than $12,000

Less than $20,000

Less than $25,000

Less than $29,000

Less than $38,000

More than $38,000

City of Alexandria Upskilling Program Screening Form

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* 2. Today's Date (MM/DD/YYYY)

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* 3. Full Name

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* 4. Contact Information

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* 5. Best way to contact you

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* 6. Date of Birth MM/DD/YYYY

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* 7. Are you eligible/authorized to work in the United States?

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* 8. Are you a veteran of the United States military?

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* 9. What is the primary language you speak at home?

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* 10. Do you need English translation assistance?

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* 11. Do you need English as a Second Language (ESL) classes?

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* 13. Do you receive any of the following benefits/public assistance? (If Yes, please select all that apply. If No, please select N/A.):

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* 14. Are you currently employed?

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* 15. Are you receiving Unemployment Insurance (UI) benefits?

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* 16. Have you received Unemployment Insurance (UI) benefits in the past?

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* 17. What is your highest level of education?

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* 18. Are you pregnant or parenting?

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* 19. Have you ever been in Foster Care?

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* 20. Are you experiencing homelessness?

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* 21. How many people live in your household?

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* 22. What is your approximate annual household income?

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* 23. Tell us about your work experience.

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* 24. Tell us what training you think would help you obtain a higher paying job.

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* 25. Tell us why this training will help you.