City of Alexandria Upskilling Program Screening Form Question Title * 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 No Question Title * 2. Today's Date (MM/DD/YYYY) Question Title * 3. Full Name Question Title * 4. Contact Information Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 5. Best way to contact you Question Title * 6. Date of Birth MM/DD/YYYY Question Title * 7. Are you eligible/authorized to work in the United States? Yes No Question Title * 8. Are you a veteran of the United States military? Yes No Question Title * 9. What is the primary language you speak at home? Question Title * 10. Do you need English translation assistance? Yes No Question Title * 11. Do you need English as a Second Language (ESL) classes? Yes No Question Title * 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? No Yes (Please specify below.) Question Title * 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) Question Title * 14. Are you currently employed? Yes No (Please enter your last day of work below.) Question Title * 15. Are you receiving Unemployment Insurance (UI) benefits? No Yes (Please enter the date of your termination letter below.) Question Title * 16. Have you received Unemployment Insurance (UI) benefits in the past? No Yes (Please enter dates you received UI benefits below.) Question Title * 17. What is your highest level of education? Question Title * 18. Are you pregnant or parenting? Yes No Question Title * 19. Have you ever been in Foster Care? Yes No Question Title * 20. Are you experiencing homelessness? Yes No Question Title * 21. How many people live in your household? Question Title * 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 Question Title * 23. Tell us about your work experience. Question Title * 24. Tell us what training you think would help you obtain a higher paying job. Question Title * 25. Tell us why this training will help you. Done