Community Job Leads

Name*

First NameMiddle NameLast Name

Birthdate (month/day/year)*

Date

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Personal Email

Confirmation Emailexample@example.com

Preferred Phone:

HomeWorkMobile

Home Phone*

Mobile Phone

Work Phone

Gender*

Race:*

Ethnicity:*

HispanicNon-HispanicClient declined to answer

Primary Language (the language most often spoken at home):*

Highest Grade Completed (If you completed education in another country, estimate the equivalent education in the U.S. Note to staff: Note the difference in a case note or employment/education assessment.):*

Vocational Training/Bridge Program History:*

No vocational training/bridge program historySome vocational training/bridge program(s)Completed vocational training/bridge program(s)Client declined to answer

Military Status:*

Criminal Convictions:*

Convicted of Misdemeanor(s) onlyConvicted of Felony(ies)No ConvictionsClient declined to answer

Marital Status:*

Household Role:*

A household is 1 or more heads of household & their dependents. This may include people who don’t live together (e.g. child at college, parent in nursing home People living together may not be in the same household (e.g. roommates who don’t blend finances

Your Household Size*

Living Arrangement - If you are incarcerated or in an institution such as a rehabilitation facility or a group home and do NOT pay rent, please select “Household stays for free".*

House/apt. is owned by household memberHouse/apt. is rented by household member – subsidizedHouse/apt. is rented by household member – unsubsidizedHousehold stays in the house/apt./room for free (no lease)Household is homeless (without a roof) or in a shelterClient declined to answer

Health Insurance Status (primary insurance only):*

Insured through a government program (e.g. Medicaid, Medicare, SCHIP)Private insurance through a household member’s employerPrivate insurance (not through a household member's employer), unsubsidizedPrivate insurance (not through a household member's employer), partially or completely subsidizedNo insurance at allClient declined to answer

Primary Interest at Program Entry (select one):*

Working at program entry? Please create an Employment record for current job.)*

In school/training at program entry?*

Yes - (Please create an Education/Training Program record for current school/training.)NoClient declined to answer

This ONLY includes earned income (wages, salaries, tips, etc.). Report your actual earned income over the last 12 months. Note that this is different from the later question about gross annual household income.

For past 12 months, earned income after tax*

A full month refers to either (1) the calendar month, or (2) any 4 continuous weeks.

For past 12 months, number of full months worked*

Community Job Leads

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