Veterans and Eligible Spouses or Persons Triage 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 Triage Form

Workforce Connections | Updated 8/19/25

This form is used to determine eligibility for additional workforce services. It is intended solely to provide Priority to Eligible Veterans and Persons that meet certain criteria. This information is being requested on a voluntary basis and will be kept confidential. Refusal to provide the information will not subject you to any adverse consequences.

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.

Email*

example@email.com*

Veteran Status*

	Yes	No
Have you served on active duty 181 or more days AND do you have anything other than a dishonorable discharge?
Are you the spouse of: 1) a totally disabled or deceased veteran whose disability or death was service-connected, or 2) an active duty service member who is currently listed as missing in action or forcibly detained by a foreign power or hostile entity for more than 90 days? OR are you the caregiver or family caregiver of a 100% disabled eligible veteran? OR are you the caregiver or family caregiver for a Wounded Warrior assigned to a Warrior Transition Unit or Military Treatment Facility?

Needs Determination for DVOP Services:*

	Yes	No
Do you have a service connected disability rating or a pending claim? (Entitled to compensation from the VA or was discharged or released from active duty for a service connected disability)
Are you currently homeless?
Are you a recently-separated service member, who at any point in the previous 12 months has been unemployed for 27 or more weeks?
Have you ever been incarcerated?
Do you lack a high school diploma or equivalent certificate?
Are you eligible to receive public assistance due to low-income status?
Are you a veteran between the ages of 18-24 years old?
Are you a transitioning service member who has not met career readiness standards and is in need of individualized career services as indicated by a DD Form 2958, between the ages of 18-24, or is being involuntarily separated through a Service reduction-in force?
Are you a Wounded Warrior assigned to a Warrior Transition Unit or Military Treatment Facility?
Are you a Vietnam Era Veteran? This is defined as active military service in Republic of Vietnam between February 28, 1961 and May 7, 1975, or service between August 5, 1964 and May 7, 1975.

Thank you for your service to our country.