Veterans and Eligible Spouses or Persons Screening Form

Economic and Workforce Development is committed to providing accessibility to everyone. If you have accessibility needs that make it difficult to complete this form, contact Blake Dowling at lcewd-ada@larimer.org or 970.498.6041.

Veterans and Eligible Spouses or Persons Screening Form

Updated 9.21.26

This form is intended to provide Priority of Service to Eligible Veterans and Persons that meet certain criteria.

We are requesting this information to best meet your employment and training needs. Any information you provide will be reflected in your Connecting Colorado profile. We will keep all information you provide to us confidential to the greatest extent allowed by law. If you do not provide this information, you will not be subjected to any adverse treatment.

Please contact our Workforce Connections Manager, Tammy Olivas, at tolivas@larimer.org or (970) 498-6626 with any questions.

Today's Date

MonthDayYear

Name

First NameLast Name

County of Residence

Example: Larimer

Zip Code

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

By providing a telephone number and submitting the form, you are consenting to be contacted by SMS text message. Message & data rates may apply. Reply STOP to opt out of further messaging.Format: (000) 000-0000.

Email

example@email.com*

Are you interested in one-on-one career planning or help finding employment?

Veteran Status: Please select any statements that apply to your service.

Rows	Yes	No
I served on active duty for more than 180 consecutive days and was discharged with other than a dishonorable discharge. (For National Guard/Reserve, active-duty training does not count toward the 180 days.)
I was released from active duty because of a service-connected disability.
I was released from active duty by reason of a sole survivorship discharge.
I was a member of a Guard/Reserve component; AND served on active duty during a period of war or in a campaign or expedition for which a campaign badge is authorized, AND was discharged or released from such duty with other than a dishonorable discharge.
Active duty: I am wounded, ill, or injured AND I am receiving treatment at a military treatment facility or soldier recovery unit.
Active duty: I am within 1 year of separation or 2 years of retirement, AND I have participated in a part of the Transition Assistance Program (TAP) including self-paced online modules and Individualized Initial Counselling.
I served on active duty for less than 180 consecutive days.

Eligible Person/Spouse Status: If you are the spouse, family caregiver, or widow(er) of someone who served or is serving in the Armed Forces, select any of the statements that apply to you.

Rows	Yes	No
I am the spouse or family caregiver of a wounded, ill, or injured current service member who is receiving care at a military treatment facility.
My spouse was a veteran who died because of a service-connected disability.
My spouse has (or my deceased spouse had) a total and permanent service-connected disability rating from the Department of Veterans Affairs.
My active-duty spouse is listed as one of the following, and has been for more than 90 days: 1) missing in action; 2) captured in the line of duty by a hostile force; or 3) forcibly detained or interned in line of duty by a foreign government power.
None of the above.

Qualifying situations for services from a Veterans' Outreach Program specialist or other workforce staff member: Select any of the statements that apply to you.

Rows	Yes	No
I have a disability, which may include any of the following: (a) I am entitled to compensation for a service-connected disability from the U.S. Department of Veterans Affairs (VA), or I currently have a disability claim pending with the VA. (b)I was released from active duty due to a service-connected disability. (c) I have another disability, meaning a physical or mental impairment that substantially limits one or more major life activities.
I am an Eligible Veteran and part of my active military, naval, or air service was during the Vietnam era, which means either: (a) I served in the Republic of Vietnam at any time between November 1, 1955, and May 7, 1975, or (b) Any part of my active duty service was between August 5, 1964, and May 7, 1975.
I was discharged or released from active duty within the last three years.
I have been referred for employment services by a representative of the U.S. Department of Veterans Affairs.
I am experiencing homelessness, including any of the following: (a) I do not have (and cannot obtain) a fixed, regular, adequate, permanent place to live. (b) I will soon lose my housing and do not have anywhere else to go. (c) I am attempting to flee domestic violence and have no safe residence or resources to obtain safe permanent housing.
I have been subjected to any stage of the criminal justice process, and/or I need assistance overcoming employment barriers resulting from a record of arrest or conviction.
I am between 18–24 years of age.
I do not have a high school diploma or equivalent certificate.
I receive (or have in the last 6 months received) public assistance through SNAP, TANF, SSI, or state or local income-based programs.
My total family income does not exceed the higher of the poverty line, or 70% of the lower living standard income level.
I am unemployed and am available to work.
I am the head of a single-parent household.
None of the above.

Thank you for your service to our country.