Registration

APPENDIX B

Study Registration Form

OMB Control No.: 1205-0482 Expiration Date: 09/30/2014 FOR COUNSELOR USE ONLY: Study ID #: | | | | | | | | | U se black or blue ink to complete this form. Make heavy dark marks that fill the square completely.
Correct Mark
Incorrect Marks		. ,	. .	X
Please PRINT where applicable. Enter only one number per box. | 1 | 9 |

1. Today’s Date: | | | / | | | / | 2 | 0 | | |

Month Day Year

2. Name:

First Name MI Last Name

2a. Maiden Name:

3. Address:

_____________________________ | | | | |

Street Apt. #

___________________ | | | | | | | | |

City State ZIP Code

4. Date of Birth: | | | / | | | / | 1 | 9 | | |

Month Day Year

5. Social Security Number:

| | | | - | | | - | | | | |

FOR COUNSELOR USE ONLY

A. LWIA Name:

B. Center Name:

C. WIA Counselor’s Name:

First Name MI Last Name

D. Customer’s Qualification status: 1 □ D

2 □ A

E. Training: F. Provider:

1 □ VL 1 □ C.C./T.C. - 2-yr.

2 □ SL 2 □ P

3 □ SU 3 □ U/C - 4-yr.

4 □ VU 4 □ O (Write in):

6. Gender:

1 □ Male

2 □ Female

7. Home Phone Number:

IF NONE, MARK HERE □

(| | | |) - | | | | - | | | | |

Area Code

Under whose name is that phone listed?

1 □ My own name 2 □ Someone else’s name (Write in):

_________________

First Name Last Name

8. Cell Phone Number:

IF NONE, MARK HERE □

(| | | |) - | | | | - | | | | |

Area Code

9. Email Address:

10. Are you of Hispanic, Latino, or Spanish origin?

1 □ Yes

0 □ No

11. What is your race?

MARK ONE OR MORE BOXES

1 □ White

2 □ Black or African American

3 □ American Indian or Alaska Native

4 □ Asian

5 □ Native Hawaiian or Pacific Islander

12. What is your primary spoken language?

MARK ONE BOX

1 □ English

2 □ Spanish

3 □ Other (Write in):

13. What is your marital status right now?

MARK ONE BOX

1 □ Married 4 □ Widowed

2 □ Separated 5 □ Never married

3 □ Divorced

CONTINUE ON BACK ►

14. Including yourself, how many people live with you? (Please include babies, small children, people who are not related to you, and people who are temporarily away.)

| | | # OF PEOPLE LIVING WITH YOU,

INCLUDING YOU

15. Which of the following degrees, diplomas, or certificates have you received?

MARK ALL THAT APPLY

1 □ None

2 □ Elementary, Middle, or Junior High diploma

3 □ High School Diploma

4 □ Adult Basic Education (ABE) certificate

5 □ General Educational Development (GED)

6 □ Vocational/Technical degree or certificate

7 □ Business degree/certificate

8 □ Associates degree (AA)

9 □ Bachelor’s degree or equivalent (BA/BS)

10 □ Master’s degree or equivalent (MA/MS)

11 □ Doctor’s degree (MD, Ph.D.)

12 □ Other professional degree/certificate

13 □ Other (Write in):

16. Do you have any health problems—mental, physical, or emotional—or substance abuse problems that limit the kind or amount of work or training that you can do?

1 □ Yes

0 □ No

17. Have you had a job in the past five years?

1 □ Yes

0 □ No GO TO #24

18. Are you currently working?

1 □ Yes GO TO #20

0 □ No

19. In what month and year did your last job end?

| | | / | 2 | 0 | | | GO TO #20

Month Year

Public Burden Statement

Completing this document, which seeks to help the U.S. Department of Labor understand the effects of WIA-funded services on customers’ employment-related outcomes, is voluntary. The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to the Office of Policy Development and Research, U.S. Department of Labor, Room N5641, 200 Constitution Avenue, NW, Washington, DC 20210.

ANSWER QUESTIONS 20-23 ABOUT YOUR CURRENT OR MOST RECENT JOB. (If you currently have more than one job or had more than one job recently, give answers about your job with the most hours.)

20. What is the name of your current or former employer?

1 □ Self-employed

21. What are (or were) your main duties at this company? PLEASE BE SPECIFIC

22. How many hours per week do (or did) you usually work at your main job?

| | | HOURS PER WEEK

23. What was your current or most recent rate of pay, before taxes and deductions at your main job?

$ | | | |,| | | | _• | | | PER

Dollars Cents

(if pay varies, enter an average amount)

MARK ONE BOX

1 □ Hour

2 □ Week

3 □ Every 2 weeks

4 □ Twice per month

5 □ Year

6 □ Other (Write in): __________________________

24. Do you or anyone in your household currently receive assistance from any of the following programs?

MARK ALL THAT APPLY

1 □ TANF (Cash assistance)

2 □ SSI or SSDI

3 □ General Assistance

4 □ SNAP (Food Stamps)

5 □ Unemployment Compensation

6 □ Other (Write in):

0 □ IF NONE, MARK HERE

25. In the past, have you ever used services at this Center or one similar to it?

1 □ Yes

0 □ No

Thank you for completing this form. Please return it to your WIA counselor.