WIOA Eligibility Survey

Name:*
What is the best phone number to reach you at?
Format: (000) 000-0000.
Email address:
Parish of Residency
Do any of these apply to you? Please check all that apply.

Did you lose your previous job through no fault of your own, as a result of a downsizing, restructuring, the COVID-19 pandemic or some similar actions?Are you recently divorced or have you become a widow/widower in the last 5 years?Do you identify as a veteran of the United State Armed Forces or National Guard?Are you a spouse of an active military member that was relocated to Louisiana (Change of Duty)?
Do you have a layoff letter?

YesNoNot sure
Are you eligible for unemployment?

YesNoNot sureI have exhausted my unemployment benefits
Do any of these apply to you? Please check all that apply

You or a family member is receiving public assistance, or has received public assistance in the last 6 months.You have a disabilityYou have been subject to any stage of the criminal justice process (felony, misdemeanor, arrest record, diversion, deferral, whether incarceration or not)?You have a belief or practice that would restrict you from some employment opportunities?You have not earned a high school diploma, GED or HiSetYou are a single parent of a child under the age of 18You are 55 or olderYou are a low income individual, which includes being homeless, a foster care youth, and a recipient of free or reduced lunch (including parents)?
What forms of public assistance are you or a member of your family currently receiving or received in the last 6 months? Please check all that apply.

SSISSDIFood Stamps/SNAPTANFChild Care Assistance ProgramRefugee AssistanceSection 8
Are you currently enrolled in a post-secondary school or training program?

YesNo
What post-secondary school or training program are you enrolled in?
What services are you interested in that are provided by the American Job Center at Geaux Jobs? If you are interested in training, what career area are you considering?
Should be Empty: