Consumer Data Sheet

Consumer Data Sheet Form
Program
Funder
Status
Start Date

MonthDayYear
Date
Case Manager
Social Security Number
Location
State ID or Drivers License Number
Expiration Date on ID

MonthDayYear
Date
Have you attended a program at Goodwill Industries of Wayne and Holmes Counties in the past?
Name
Maiden Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Gender
Race
Marital Status
Conditions/Ancillary Services (services you are using and/or agencies you are connected with)

180Cash RecipientChildren's ServicesEnergy AssistanceFood StampsFederal Earned Income Tax CreditMedicaid/Medicare or Medical CardMental Health ProviderSSI/SSDI
Notes
Disability and Medical

AutismBlindness/Visual ImpairmentDeafnessDevelopmental Disability (Other than Autism)Has DentistHas Eye DoctorHas General PractitionerHas Mental Health CounselorLearning Disability (Other than Autism)Neurological DisabilityOther Disabling ConditionOther Physical DisabilityPregnancyPsychiatric/Emotional DisabilityPTSD
Notes
Living Arrangement
Notes
Education/Literacy and Special Skills

License or CertificationHas some computer skillsHas an Associate's DegreeHas a Bachelor's DegreeHas a GED or HS DiplomaHas a Master's DegreeHas a short term Secondary Credential (like STNA)Is able to do math at a 5th grade levelIs able to read at a 5th grade levelPursuing an Associate's DegreePursuing a Bachelor's DegreePursuing a GED or HS DiplomaPursuing a Master's DegreePursuing a short term Secondary Credential (like STNA)
GED or HS Diploma   Date
Name of Institution   Type a label
Associate's Degree Received        Date
Associate's Degree Major       Type a label
Name of Institution   Type a label
Bachelor's Degree Received        Date
Bachelor's Degree Major       Type a label
Name of Institution   Type a label
License or Certification Received Date
License or Certification Name Type a label
Master's Degree Received        Date
Master's Degree Received       Type a label
Name of Institution   Type a label
Secondary Credential Received        Date
Secondary Credential Received       Type a label
Name of Institution   Type a label
Military Affiliation (Army, Navy, Airforce, Marines, CG)   Type a label
Branch      Type a label
Rank   Type a label
Special Skills and Hobbies
Transportation

Drives and has own transportationFamily or friend transportsMR/DDTaxi or Public Transit
Legal History

Credit IssuesFelony RecordProbation or ParoleSex Offender
Notes
Has Mentors and Natural Support System
Self Reported Cultural Barriers
Self Reported Gender or Sexual Preference Barriers
Self Reported Language Barriers
Self Reported Racial Barriers
Self Reported Religious Barriers
Self Reported Social Barriers
Self Reported Socio Economic Barriers
Other Barriers (Things you Need)

Access to Reliable TransportationBirth Certificate (Children)Birth Certificate (Self)Car InsuranceCar SeatsDaycareDrivers LicenseGreen CardPermitSocial Security CardState ID
Client Signature

Clear
Parent or Guardian Signature

Clear
Date

MonthDayYear
Date
Case Manager to Complete - Occupational Skill (WFT Only)

ClericalFood ServiceJanitorialOffice ManagementProductionRetail
Assessment - OOD Only

ClericalCommunityJanitorialProductionRetail
General Information - Case Manager - please note the clients physical appearance and hygiene, communication and social skills ad mental and emotional status
General Information - Case Manager - please note self reported strengths, abilities, preferences hobbies and interests in addition to any barriers (including knowledge of job seeking techniques, attendance, knowledge of job quality and quantity, work related time and money management skills, knowledge of work practices such as payroll deductions and union requirements, issues with anger or conflict management, lack of customer service skills and knowledge of work ethic and general corporate culture. Does this client have health and safety or other risks that will interfere with the fulfillment of goals or outcomes? Please explain.

Consumer Data Sheet Form