Refugee Self-determination Survey
Name
First Name
Last Name
Date of Interview
-
Month
-
Day
Year
Date
Name of Interviewer
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Phone number updated?
No
Yes
Email
example@example.com
Email updated?
No
Yes
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Date of Arrival (in RI)
/
Month
/
Day
Year
Date
Notes
Self Sufficiency Survey
Are you working with any organizations in RI? (Dorcas, Catholic Diocese, etc.)
Highest Education Level completed
Elementary
Middle
High School
University
Graduate
Skills training
Other
English Proficiency
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Are you receiving any State benefits?
RCA
SNAP
Medicaid
Are you working?
Do you have your work permit?
Do you need help getting a job?
Please Select
Yes
No
Other
Do you need help learning English?
Please Select
Yes
No
Other
What did you do for work in your home country?
What are your goals for your life in RI?
Healthcare Questions
Do you have a doctor?
Do you have any health issues?
Would you like help getting medical assistance?
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Recommended Referrals
Referrals
English Classes (Dorcas, Genesis)
Help getting a job (resume assistance, Financial Opportunities Clinic)
Specialized training - CDL
Specialized training - CNA
Specialized training - continuing education
Benefits coordination
Case Management
Immigration
Transportation
Healthcare (Navigate Health)
Child Care
Other
Submit
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