ROSS Enrollment Assessment

ROSS Enrollment Assessment
To be a participant of the Resident Opportunity and Self Sufficiency (ROSS) Program at Northwest Minnesota Multi-County HRA, you must complete the enrollment. Please Note: without the enrollment completed, we will not be able to procide you with supportive services or supplemental funding grants/scholarships.
Date*

MonthDayYear
Date
Full Name*
Sex*

MaleFemaleDecline
Address*

Street Address

APT #

CityState / Province

Zip Code
Do you have a phone number we can reach you at?*

YesNo
Phone Number*
Format: (000) 000-0000.
Phone Type*

Cell PhoneLandline
Do you have an email address we can reach you at?*

YesNo
Email Address*
example@example.com
Do you have access to internet?*

YesNo
Do you have a device to access the internet?*

YesNo
What type of device(s)? Check all that apply*

LaptopDesktopSmartphoneTabletOther
Are you able to read and write in English?*

YesNo
If no, what is your primary language?*
Are you a veteran?*

YesNoWidowDecline
If yes, do you receive veteran benefits?*

YesNo
Do you have adequate transportation?*

YesNo
Supportive Services
Please check which of the following benefits you are receiving. When you check a benefit, a box will appear below to enter the MONTHLY amount you receive.

If you do not receive any of the following benefits, select not applicable.
Benefit Type*

Medical Assistance/MinnesotaCareMinnesota Family Investment Program (MFIP)Child Care Assistance Program (CCAP)Supplemental Nutrition Assistance Program (SNAP)General Assistance (GA)/Cash Assistance (CA)Temporary Assistance for Needy Families (TANF)Minnesota Supplemental Aid (MSA)Diversionary Work Program (DWP)UnemploymentSSI/SSDINot Applicable
MONTHLY amount of MFIP received*
MONTHLY amount of CCAP received*
MONTHLY amount of SNAP received*
MONTHLY amount of GA/CA received*
MONTHLY amount of TANF received*
MONTHLY amount of MSA received*
MONTHLY amount of DWP received*
MONTHLY amount of unemployment received*
MONTHLY amount of SSI/SSDI received*
Please check which of the following services you would like to access as a participant of the ROSS program.

If you do not wish to receive any of the above services, please select not applicable.
Service Options*

Budgeting/Financial CounselingJob PlacementTransportation AssistanceCreating/Updating a ResumeObtaining Driver's LicenseFood SecurityCareer CounselingEducation/GED AssistanceHealthEnglish as Second Language ClassesIncrease SavingsUtility AssistanceChild CareAge & Stay in PlaceHomeownershipHousehold/Life Skills TrainingDebt ReductionNot Applicable
Housing
Do any of the factors listed below affect your ability to get/maintain housing?

If none apply to you, select not applicable.
Factors*

Lack of EducationDisabling ConditionPoor Rental HistoryPoor Credit HistoryCriminal BackgroundUnpaid Rent/UtilitiesNot ApplicableOther
Do you have basic furnishings (beds, chairs, kitchen items, etc.) for your home?*

YesNo
Do you have any concerns related to employment that you would like to address?*

YesNo
If yes, please BRIEFLY explain:*
Employment
Are any household members employed?*

YesNo
How long have you been unemployed?*
Are you looking for work?*

YesNo
Reason for being unemployed:*

Never WorkedLaid OffFiredQuitRetiredOn DisabilityEnrolled in School/Training Program
How many jobs do you have to add?*
JOB #1
Name of Household Member*
Place of Employment*
Start Date - MONTH & YEAR*
MM/YYYY FORMAT
Hours per week*
Hourly Wage*
JOB #2
Name of Household Member*
Place of Employment*
Start Date - MONTH & YEAR*
MM/YYYY FORMAT
Hours per week*
Hourly Wage*
JOB #3
Name of Household Member*
Place of Employment*
Start Date - MONTH & YEAR*
MM/YYY FORMAT
Hours per week*
Hourly Wage*
Financial
For the following question, incomes would include non public assistance or employment income such as Child Support, Social Security, Alimony/Spousal Maintenance, Pension, Annuities, Income from Rental Property, etc.
Does your household have monthly income from any other source?*

YesNo
How many incomes do you have to add?
INCOME #1
Name of Household Member*
Source of Income*
MONTHLY Amount Received*
INCOME #2
Name of Household Member*
Source of Income*
MONTHLY Amount Received*
INCOME #3
Name of Household Member*
Source of Income*
MONTHLY Amount Received*
INCOME #4
Name of Household Member*
Source of Income*
MONTHLY Amount Received*
Are you able to pay for basic necessities without debt accumulation?*

YesNo
Please BRIEFLY Explain*
Did you receive an Earned Income Tax Credit (EITC) for the most recent tax year?*

YesNo
Do you have a checking account?*

YesNo
Do you have a savings account?*

YesNo
Do you have an IDA (Individual Development Account)?*

YesNo
What is the account for?*

HomeownershipEducationBusinessOther
What is your MONTHLY household cost for transportation?*
Include vehicle payments, vehicle insurance, gas, bus tickets, etc.
Do you pay for childcare?*

YesNo
MONTHLY cost of childcare*
If you are receiving assistance, ONLY INCLUDE THE AMOUNT YOU PAY OUT OF POCKET, not the full amount.
Education
What is the highest level of education you have completed?*

High School GraduateGED ObtainedDropped Out
Month & Year Completed*
MM/YYYY FORMAT
Month & Year Completed*
MM/YYYY FORMAT
Highest Grade Level Completed*
Are you currently enrolled in a post-secondary program?*

YesNo
What type of program?*

AssociatesBachelor'sMaster'sPhDCertificateTrade OR Vocational
Enrollment Date - MONTH & YEAR*
MM/YYYY FORMAT
Are you interested in going back to school?*

YesNo
Have you previously attended college?*

YesNo
Select ALL applicable years completed:*

Less than 1 year of College Credits1 or more years of college credits, but no degreeAssociate DegreeBachelor's DegreeMaster's DegreePhDCertificateTrade/Vocational
MONTH & YEAR Completed Associate Degree*
MM/YYYY FORMAT
MONTH & YEAR Completed Bachelor's Degree*
MM/YYYY FORMAT
MONTH & YEAR Completed Master's Degree*
MM/YYYY FORMAT
MONTH & YEAR Completed PhD*
MM/YYYY FORMAT
MONTH & YEAR Completed Certificate*
MM/YYYY FORMAT
MONTH & YEAR Completed Trade/Vocational*
MM/YYYY FORMAT
Health
Are you able to perform all activities of daily living (ADLs) without assistance?*

YesNoDecline
Which activities do you need assistance with?*

Ambulation/LocomotionBathingGroomingToiletingTransferringDressingFeeding or Eating
Are you able to perform all instrumental activities of daily living (IADLs) without assistance?*

YesNoDecline
Which activities do you need assistance with?*

Handling TransportationHousekeeping & Other Basic Home MaintenanceManaging MedicationsManaging Money/Sorting PaperworkPreparing MealsUsing the Phone/Operating Home EquipmentShopping
Do you have a disability as defined by the American with Disabilities Act and determined by a physician, Medicaid, or other authority?*

YesNoDecline
What type of disability?*

Physical DisabilityMental DisabilityBoth Physical & Mental DisabilitiesDecline
Do you have health insurance?*

YesNo
What type of insurance? Select all that apply*

Through EmployerMedicareMedicaid/Medical AssistancePrivate InsuranceOther
Do you need help applying for health insurance?*

YesNo
Do you have a primary care physician?*

YesNoDecline
Have you received a routine medical examination by a health care provider in the past 12 months?*

YesNoDecline
MONTH & YEAR of last medical examination*
MM/YYYY FORMAT
Do you have a dentist?*

YesNoDecline
Have you had a routine dental examination in the past 12 months?*

YesNoDecline
MONTH & YEAR of last dental examination*
MM/YYYY FORMAT
Are you currently being treated for substance abuse or dependence, or have you been treated in the past 12 months?*

Yes, currently being treatedNot currently being treated, but have in the pastNever been treated for substance abuse or dependenceDecline to answer
Start Date of Treatment - MM/DD/YYYY Format*
MONTH, DAY, AND YEAR
MONTH & YEAR of Last Treatment*
MM/YYYY FORMAT
Goals

Please list five goals that you would like to accomplish through the ROSS program that would assist you in becoming self-sufficiency and/or assist you to age in place.
Goal #1*
Goal #2*
Goal #3*
Goal #4*
Goal #5*
ROSS Program Enrollment Acknowledgement & Agreement
By signing this form, I voluntarily chose to participate in the ROSS program. I understand taht the program caseworker or coordinator will reach out regularly to check in and I will be expected to work towards achieving goals I have set for myself.

I understand that participation in the ROSS Program is required to receive any supportive services, referrals, or scholarships/grants that may be available to myself and/or my household under the ROSS Program. Participation involves having regular contact with the Self Sufficiency Casework and/or Coordinator. I also understand that any scholarship/grant payments are not guarenteed, must be approved, can be denied, and are based on current funding.

I understand that information obtained by the Self Sufficiency Caseowker and/or Coordinator will be maintained as confidential and released only to those employees at Northwest Minnesota Multi-County HRA who have a need to know such information, as required by law.

I understand that in order to be referred for services outside of Northwest Minnesota Multi-County HRA, I must sign a release of information. The Self Sufficiency Caseworker and/or Coordinator will not be able to release any information to an outside agency without a signed release.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

ROSS Enrollment Assessment

Supportive Services

Housing

Employment

Financial

Education

Health

Goals

ROSS Program Enrollment Acknowledgement & Agreement