TANF Recipient Case Management Survey

Note: Effective November 1, 2024, LWDB staff are no longer required to generate an intake survey using this form and are no longer required to enter Activity Code 28 - Intake Survey into OSST. Intake survey data will be collected in OSST from the answers the participant provides when completing the Needs and Barriers assessments. The exit section is still viable.

There are three scenarios for completing this form. Please follow the instructions for your scenario.

What will you be doing today?* This field is required.

Completing the Exit Section without completing the Intake Section.

Case Manager* This field is required.

First Name

Last Name

Case manager email address* This field is required.

example@example.com

Confirm Email

Local Workforce Development Board* This field is required.

Recipient Name* This field is required.

First Name

Last Name

Recipient's FLORIDA (RFA) case number or FLORIDA pin number, if known.

What are your current barriers to employment?* This field is required.

Criminal history

Drug and alcohol treatment needed

Flexible work schedule needed

Homeless

In a domestic violence shelter

Lack of childcare

Lack of education

Lack of marketable skills

Lack of transportation

Lack of work experience

Limited English proficiency

Long gaps in employment

Medical limitations

Not authorized to work in the US

Providing care to another person

Other

What reason(s) separated you from employment within the previous 12 months?* This field is required.

Enrolled in full-time training

Health reasons

Layoff / downsizing

National or Local disaster

Quit

Reduction in hours

Relocation

Retirement

Seeking better work conditions

Substance abuse

Terminated

Other

What are your goals for employment or professional development?* This field is required.

Career switch

Earn a certificate / credential

Earn a degree (AS, AA, BS,MS)

Expand your professional network

Find a mentor

Gain new skill and experiences

Get a remote job / work from home

Improve your work-life balance

Looking for full-time position

Looking for part-time position

Obtaining a leadership position

Personal development

Start a business

Other

What is the highest level of education or credentials you have received?* This field is required.

No Formal Schooling

1st grade completed

2nd grade completed

3rd grade completed

4th grade completed

5th grade completed

6th grade completed

7th grade completed

8th grade completed

9th grade completed

10th grade completed

11th grade completed

12th grade completed

GED

High school diploma

Vo-Tech less than 12 months

1 year of Technical or Vocational School

2 years of Technical or Vocational School

3 years of Technical or Vocational School

Vocational School Certificate

1 year in college with no degree

2 years in college with no degree

3 years in college with no degree

4 years in college with no degree

Associate Degree Awarded

Bachelor Degree Awarded

Masters Degree Awarded

Doctorate Degree Awarded

Specialized Degree (e.g. MD, DDS)

Other Diploma/Certificate Awarded

Are you aware of the Welfare Transition services we provide?* This field is required.

YESNO

This completes the intake section questions. Click Go to Submit if you are done with the intake section. Click Continue to Exit Section if you are continuing the form from an edit submission URL.

Go to Submit

Continue to Exit Section

Click Submit to receive an email with a unique URL. Use that URL to complete the exit section of the form at the appropriate time for {RecipientName}. If you wish to retain a copy of your entries, you will be presented a download option upon submission.

You indicated the following barriers to employment during the intake survey for {RecipientName}. If these have changed, please make your modifications below. Otherwise, click Next.* This field is required.

Criminal history

Drug and alcohol treatment needed

Flexible work schedule needed

Homeless

In a domestic violence shelter

Lack of childcare

Lack of education

Lack of marketable skills

Lack of transportation

Lack of work experience

Limited English proficiency

Long gaps in employment

Medical limitations

Not authorized to work in the US

Providing care to another person

Other

Is {RecipientName} enrolled in other public benefits programs at the time of exit?* This field is required.

YESNO

What are {RecipientName}'s enrollments in other public benefits programs at the time of exit?* This field is required.

Supplemental Nutrition Assistance Program (SNAP)

Free or Reduced Price School Meals

Women, Infants and Children Nutrition Program (WIC)

Child Care Subsidy (CCDF)

HeadStart/Early Head Start

State-Funded Pre-Kindergarten

Section 8 Housing Voucher

Medicaid for Adults

Medicaid for Children/CHIP

Temporary Assistance for Needy Families (TANF)

Health Insurance Marketplace Subsidy

Earned Income Tax Credit (EITC)

Child Tax Credit (CTC)

Child and Dependent Care Tax Credit (CDCTC)

Supplemental Security Income (SSI)

Social Security Disability Insurance (SSDI)

Transitional Books

Transitional Child Care

Transitional Clothing

Transitional Counseling

Transitional Education

Transitional Fees/Licenses

Transitional Job Retention Services

Transitional Life Management Skills

Transitional Parenting Education

Transitional Transportation

Transitional Tools

What are {RecipientName}'s enrollments in other public benefits programs at the time of exit?* This field is required.

Does {RecipientName} have a long-term career plan?* This field is required.

YESNO

What is {RecipientName}'s long-term career plan?* This field is required.

Looking for full-time position

Get a remote job / work from home

Gain new skill and experiences

Earn a certificate / credential

Improve your work-life balance

Personal development

Earn a degree (AS, AA, BS,MS)

Looking for part-time position

Start a business

Expand your professional network

Obtaining a leadership position

Career switch

Find a mentor

Other

What is {RecipientName}'s long-term career plan?* This field is required.

Did {RecipientName} attain any credentials, education or training during enrollment?* This field is required.

YESNO

What credentials, education attainment, or training did {RecipientName} receive during enrollment?* This field is required.

What barriers to {RecipientName}'s employment were addressed during enrollment?* This field is required.

Criminal history

Drug and alcohol treatment needed

Flexible work schedule needed

Homeless

In a domestic violence shelter

Lack of childcare

Lack of education

Lack of marketable skills

Lack of transportation

Lack of work experience

Limited English proficiency

Long gaps in employment

Medical limitations

Not authorized to work in the US

Providing care to another person

Other

Do any barriers remain to {RecipientName}'s employment?* This field is required.

YESNO

What barriers remain to {RecipientName} being employed?* This field is required.

Criminal history

Drug and alcohol treatment needed

Flexible work schedule needed

Homeless

In a domestic violence shelter

Lack of childcare

Lack of education

Lack of marketable skills

Lack of transportation

Lack of work experience

Limited English proficiency

Long gaps in employment

Medical limitations

Not authorized to work in the US

Providing care to another person

Other

What barriers remain to {RecipientName} being employed?* This field is required.