CHARACTERISTICS AT PLAN

Narrative: The Workforce Innovation & Opportunity Act (WIOA) requires Michigan Rehabilitation Services (MRS) and other workforce programs to collect information on factors which may result in barriers to employment. In addition to assisting your MRS counselor to more fully understand your unique needs, the questions below may help your counselor locate other community resources and benefits that will assist you.

Instructions:

Complete this form before beginning the first Individualized Plan for Employment (IPE
If employed, provide requested employment information in Section 1.
For each question below in Section 2, review the reasons why applicant would select “Yes,” and then select “Yes,” or “No,” as appropriate.

Name*

First NameMiddle NameLast Name

Mailing Address*

City*

State*

Zip Code*

Highest Elementary/Secondary Level Completed (Grades 1-12)*

Highest Postsecondary Level Completed

Credentials Earned*

Credentials*

	Date Attained
Associate's Degree
Bachelor's Degree
Degree Beyond Master's
Master's Degree
High School Diploma
GED
None
Other Diploma, Degree, or Certificate
Special Education Certificate or Diploma
Vocational/Technical Certificate
Vocational/Technical License

Section 2: Employment Status at Plan

(Leave this section blank if applicant is not currently employed)

What is applicant’s job title?*

Is this self-employment?*

YesNo

How many hours does applicant work per week?*

What is applicant's wage/salary, including tips?*

Is this:*

Per HourPer WeekPer MonthPer Year

Customer Name*

Employment Status at Plan Continued*

	Yes	No
Are there opportunities for advancement at applicant’s current place of employment?
Has applicant received a Notice of Termination?
Has applicant received a Worker Adjustment & Retraining Notification (WARN)?
Is applicant a transitioning service member? (for example: Army, Navy, Air Force, Marine Corps, Coast Guard, etc.)

Is applicant Long-Term Unemployed?

Select “Yes” if applicant is now unemployed and has been unemployed for the previous 27 (or more) consecutive weeks regardless of his/her age or school status.*

YesNo

Program Involvement at Plan*

	Yes	No
Adult Education (Adult Education and Literacy)
Job Corps
Wagner-Peyser Employment Services (Michigan Works)
WIOA Adult Program
WIOA Youth Program
WIOA Dislocated Worker Program
Youth Builder
None

1. Is or was applicant in foster care? Select “Yes” if applicant is under the age of 25 and one of these is true: •Applicant is currently in a foster care program, or •Applicant was formerly in a foster care program and has since aged out.*

YesNo

2.Does applicant qualify as someone who is “homeless”? Select “Yes” if: •Applicant is living with others or in a shelter due to economic hardship or lack of adequate accommodations, or •Applicant stays at night in a car, abandoned building, airport, park or other public or private place not ordinarily used as a place for sleeping, or •Applicant is under the age of 18 and has left home without permission or is waiting for foster care.*

YesNo

Customer Name*

3.Does applicant qualify as someone who is an “ex-offender”? Select “Yes” if: •Applicant has been subject to any stage of criminal justice process for committing a status offense* or delinquent act**, or •Requires assistance in overcoming barriers to employment resulting from a record of arrest or conviction.*

YesNo

*Status Offender definition: Per the Office of Juvenile Justice and Delinquency, a status offense is a noncriminal act that is considered a law violation only because of a youth’s status as a minor. Typical status offenses include truancy, running away from home, violating curfew, underage use of alcohol, and general ungovernability.

**Delinquent Act definition: Per the Office of Juvenile Justice and Delinquency, a delinquent act is an act committed by a juvenile for which an adult could be prosecuted in a criminal court, but when committed by a juvenile is within the jurisdiction of the juvenile court. Delinquent acts include crimes against persons, crimes against property, drug offenses, and crimes against public order, when juveniles commit such acts. Office of Juvenile Justice and Delinquency.

4.Does applicant qualify as someone who has “low income”? Select “Yes” if: •Applicant is homeless, or a youth living in a high poverty area, or •Applicant is a youth in foster care or a student eligible for free or reduced-price lunch, or •Applicant or the family with whom applicant lives either receive now or received in the six months before applying for services one or more of the following: SSI, state or local income-based public assistance, or food stamps (SNAP), or •Applicant’s own income is at or below the poverty line or applicant is in a family whose total income does not exceed the higher of the U.S. poverty guideline (Reference: https://www.doleta.gov/llsil/) or 70% of the lower living standard income level.*

YesNo

5.Applicant has limited English skills? Select “Yes” if applicant has limited ability to speak, read, write, or understand English, and one or more of these statements are true: •English is applicant’s second language, or •English is not the primary language in the family or community in which applicant lives*

YesNo

Customer Name*

6. Does applicant have a low level of literacy or is applicant lacking in basic skills? Select “Yes” if: •Applicant is under the age of 25 with less than 8 grade reading, writing or math skills on standardized school tests, or •Applicant is a youth or adult who is unable to use English to read and write or to use math at a level needed to maintain employment or function at home or in the community.*

YesNo

7. Does applicant have any cultural barriers to employment? Select “Yes” if applicant has attitudes, beliefs, customs, or practices derived from applicant’s cultural experience which may hinder employment. Note: Applicant may choose not to self disclose.*

YesNo

8. Is applicant a single parent? Select “Yes” if applicant is single, separated, divorced, or widowed and either is pregnant or has a dependent child less than age 18.*

YesNo

9. Is applicant a displaced homemaker? Select “Yes” if: •Applicant previously provided unpaid service to family members in the home, and •Applicant is now unemployed or underemployed and having trouble in obtaining or upgrading employment, and •One of these statements is true: -Applicant was dependent on the income of another family member but is no longer supported by that income, or -Applicant is the dependent spouse of a member of the Armed Forces whose family income has been significantly reduced because of deployment, a call or order to active duty, a permanent change of station, or service-connected death or disability.*

NoYes

10. Is Applicant a migrant or seasonal farmworker? Select “Yes” if: •Applicant qualifies as one who has “low income” (above), and has been primarily employed in agriculture or fish farming labor for 12 months during the two years prior to applying for MRS services, and has been chronically (persistently) unemployed or underemployed, and now faces multiple barriers to economic self-sufficiency, or •Applicant is a seasonal farmworker whose agricultural labor requires travel to a job site such that he or she is unable to return to a permanent place of residence within the same day, or •Applicant is dependent on someone described above as a seasonal or migrant farmworker.*

YesNo

Customer Name*

11. Applicant will exhaust TANF (Family Independence Program (FIP within the next two years? Select “Yes” if: •Applicant is receiving FIP now or has received FIP previously, and •Applicant is within two years of exhausting lifetime eligibility for FIP even if applicant is not currently receiving FIP benefits at the time of the initial IPE Applicant is within two years of exhausting the lifetime benefit if he or she has received FIP for at least 36 total months any time during his or her lifetime.*

YesNo

12. Are there any other barriers applicant faces that have not been listed within this form?*

YesNo

CHARACTERISTICS AT PLAN

Customer Information

Section 1: Education at Plan

Date Attained

Section 3: Program Involvement at Plan

Section 4: Barriers to Employment