CRS Prescreening Form
Date
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Month
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Day
Year
Date
Name
First Name
Last Name
County to work in
Does the applicant meet all of the following regulatory requirements:
A minimum of 18 months in a continuous manner of personal, lived experience
A copy of the high school transcript or diploma is acceptable or GED verification; OR college degree documentation can be used in lieu of a high school diploma/GED. The degree must be from anaccredited college/university that is recognized by the US Department of Education or the Council on HigherEducation Accreditation. An official transcript sent directly from college/university is required.
Has worked at least 12 months out of the past 36 months off work or volunteer experience
Have you ever been convicted of a crime(felony or misdemeanor)? (A conviction does not automatically bar you from employment.) Please write in yes or no. If yes, please provide details
Would the applicant eventually prefer:
Full Time Status
Part Time Status
Does the applicant have a reliable transportation:
Yes
No
Name of Screener
Submit
Should be Empty: