1 Employment Navigator Intake Form

OMB Control Number: 1293-XXXX Expiration Date: XX/XX/XXXX
Employment Navigator Data Entry Layout
Element Number	Element Name	Description	Valid Values	Data Type/Field Length
1	Unique ID	Automatically generated field from case management system	XXXXXXXXXX	AN10
2	Social Security Number	The participant's Social Security Number	XXXXXXXXX	AN9
3	Client Type	Enter the correct code value for the participant	1 = Transitioning Service Member 2 = Spouse 3 = Transitioning Service Member (Warm Handover)	IN1
4	Date of First Contact	Record the date the participant first contacted an Employment Navigator	MMDDYYYY	Date8
5	Separation Date	Enter the anticipated separation date if in the future, or the actual separation date if in the past.	MMDDYYYY	Date8
6	Sex	Enter the gender of the participant	1 = Male 2 = Female 3 = Other, or did not disclose	IN1
7	Year of Birth	Select the year the participant was born	YYYY	IN4
8	Individual with a Disability (WIOA)	Record 1 if the participant indicates that he/she has any "disability”, as defined in Section 3(2)(a) of the Americans with Disabilities Act of 1990 (42 U.S.C. 12102). Under that definition, a "disability" is a physical or mental impairment that substantially limits one or more of the person's major life activities. Record 0 if the participant indicates that he/she does not have a disability that meets the definition. Record 9 if the participant did not self-identify.	1 = Yes 0 = No 9 = Participant did not self-identify	IN1
9	Highest Education Attained	Select the highest level of education attained by the participant at the time of service.	1 = Attained secondary school diploma 2 = Attained a secondary school equivalency 3 = The participant with a disability receives a certificate of attendance/completion as a result of successfully completing an Individualized Education Program (IEP) 4 = Completed one of more years of postsecondary education 5 = Attained a postsecondary technical or vocational certificate (non-degree) 6 = Attained an Associate's degree 7 = Attained a Bachelor's degree 8 = Attained a Masters degree 9 = Attained more than a Masters degree 0 = No Educational Level Completed	IN1
10	Branch of Service	Select the military branch in which the participant currently serves, or most recently served.	1 = Air Force 2 = Army 3 = Coast Guard 4 = Marine Corps 5 = Navy	IN1
11	AD/NG/Reserve Status (Last Duty Status)	Select the current or most recent duty status of the participant.	1 = Active Duty 2 = National Guard 3 = Reserve	IN1
12	Military Paygrade	Select the current or most recent military paygrade of the participant.	E-E9; O1-O10; W1-W5	AN3
13	Current Location Installation	Select the location in which the participant has received services	NS Norfolk, VA Camp Pendleton, CA JB Pearl Harbor-Hickam, HI MCAS Miramar, CA Fort Benning, GA Fort Sill, OK Cherry Point, NC Travis AFB, CA MCAB Okinawa, Japan USAG Bavaria, Germany CFA Yokosuka, Japan Joint Base Charleston, SC Kadena AB, Okinawa, Japan	AN50
14	Home State	Enter the participant's home state. Home state is defined as the last state resided in before joining the military.	Drop-down list of 50 state mailing codes, plus PR, VI, DC.	AN2
15	First Name	Enter the participant's first name	XXXXXXXXXX	AN50
16	Last Name	Enter the participants last name	XXXXXXXXXX	AN50
17	Personal Phone Number	Enter the phone number of the participant	(XXX)XXX-XXXX	IN10
18	Personal Email Address	Enter the non-military email address of the participant	XXXXXX@XXX.XXX	AN50
19	Personal Email Address #2 (optional)	Enter a second personal email address, if desired	XXXXXX@XXX.XXX	AN50
20	Preferred Contact Method	Enter a value for the preffered method to contact the participant, if necessary.	1 = Call personal phone 2 = Text personal phone 3 = Email address #1 4 = Email address #2
21	Preferred Post-Military Location City1	Enter the most desired city the participant wishes to move to after military transition	City	AN50
22	Preferred Post-Military Location State1	Enter the most desired state the participant wishes to move to after military transition	State	AN50
23	Preferred Post-Military Location Country1	Enter the most desired country the participant wishes to move to after military transition	Country	AN50
24	Preferred Post-Military Location City2	Enter the second-most desired city the participant wishes to move to after military transition	City	AN50
25	Preferred Post-Military Location State2	Enter the second-most desired state the participant wishes to move to after military transition	State	AN50
26	Preferred Post-Military Location Country2	Enter the second-most desired country the participant wishes to move to after military transition	Country	AN50
27	Occupation of Interest	Identify the occupation the participant is most interested in pursuing post-transition		AN50
28	Industry of Interest	Identify the industry the participant is most interested in pursuing post-transition	1 = Agriculture, Forestry, Fishing and Hunting 2 = Mining, Quarrying, and Oil and Gas Extraction 3 = Utilities 4 = Construction 5 = Manufacturing 6 = Wholesale Trade 7 = Retail Trade 8 = Transportation & Warehousing 9 = Information 10 = Finance & Insurance 11 = Real Estate, Rental, & Leasing 12 = Professional, Scientific, and Technical Services 13 = Management of Companies and Enterprises 14 = Administrative and Support and Waste Management and Remediation Services 15 = Educational Services 16 = Health Care and Social Assistance 17 = Arts, Entertainment, and Recreation 18 = Accomodation and Food Services 19 = Other Services (except Public Administration) 20 = Public Administration	AN50
29	Date Attended Employment Workshop	Enter the date the participant attended the TAP Employment Workshop. Leave blank if not atttended.	YYYYMMDD	Date8
30	Date Attended Career and Credential Exploration (C2E) Workshop	Enter the date the participant attended the TAP C2E. Leave blank if not atttended.	YYYYMMDD	Date8
31	Work Availability Date	Enter the date the participant is available to begin work.	YYYYMMDD	Date8
32	Career Goal	Indicate the most desired post-transition goal.	1 = Employment (non-apprenticeship) 2 = Continuing Education 3 = Apprenticeship 4 = Entrepreneurship 5 = Unsure	IN4
33	Career Pathway: Networking	Indicate if the participant would benefit from networking exposure as part of the career pathway.	1 = Yes, and was referred to a partner entity 2 = Yes, but participant was not interested/refused service 3 = No, would not be beneficial	IN1
34	Career Pathway: Mentorship	Indicate if the participant would benefit from mentorship as part of the career pathway.	1 = Yes, and was referred to a partner entity 2 = Yes, but participant was not interested/refused service 3 = No, would not be beneficial	IN1
35	Career Pathway: Job Training	Indicate if the participant would benefit from job training as part of the career pathway.	1 = Yes, and was referred to a partner entity 2 = Yes, but participant was not interested/refused service 3 = No, would not be beneficial	IN1
36	Career Pathway: Job Placement	Indicate if the participant would benefit from direct job placement services as part of the career pathway.	1 = Yes, and was referred to a partner entity 2 = Yes, but participant was not interested/refused service 3 = No, would not be beneficial	IN1
37	Career Pathway: Apprenticeship	Indicate if the participant would benefit from an apprenticeship program as part of the career pathway.	1 = Yes, and was referred to a partner entity 2 = Yes, but participant was not interested/refused service 3 = No, would not be beneficial	IN1
38	Career Pathway: Hiring Events	Indicate if the participant would benefit from attending a hiring event/fair as part of the career pathway.	1 = Yes, and was referred to a partner entity 2 = Yes, but participant was not interested/refused service 3 = No, would not be beneficial	IN1
39	Career Pathway: Wrap-Around Services	Indicate if the participant would benefit from any additional supportive services, such as: housing assistance, logistics and transportation, recreation/fitness, child care, financial aid, etc. as part of the career pathway.	1 = Yes, and was referred to a partner entity 2 = Yes, but participant was not interested/refused service 3 = No, would not be beneficial	IN1
40	Services Received: Resume Review	Indicate the most recend date that resume review was provided to the participant by an Employment Navigator. Leave blank if not provided.	YYYYMMDD	Date8
41	Services Received: Skills & Interest Assessment Review	Indicate the most recent date that the skills and interest assessment was provided by an Employment Navigator and/or reviewed if previously done. Leave blank if not provided.	YYYYMMDD	Date8
42	Services Received: Labor Market Information	Indicate the most recent date that labor market information was provided by an Employment Navigator to the participant. Leave blank if not provided.	YYYYMMDD	Date8
43	Services Received: Apprenticeship Overview	Indicate the most recent date that information regarding potential apprenticeship opportunities was provided by an Employment Navigator to the participant. Leave blank if not provided.	YYYYMMDD	Date8
44	Services Received: Application submittal (employer or apprenticeship program)	Indicate the most recent date that an application was submitted on behalf of the participant. Leave blank if not provided.	YYYYMMDD	Date8
45	Not Interested/Refusal Reason	If the participant refused any of the above services, record reason for refusal.	1 = Doesn't think this will help them 2 = Cost factor is an issue 3 = Service isn't available in the desired/future location 4 = Doesn't have available time to participate in the service or activity 5 = Not enough information or not ready to make an informed decision 6 = Other
46	Not Interested/Refusal Reason (Other)	If data element #XX = 6, please identify the reason as provided by the participant.	Insert Text	AN50
47	Warm Handover or Connection Type	Select the type of entity that was referred to the participant	1= American Job Center (Warm Handover) 2 = Approved DOL Partner (non-AJC) 3 = VA Partner (e.g. benefits counselor) 4= DoD Partner 5 = Education entity 6 = Technical Training 7 = Other 8 = No Warm Handover or Connection	IN1
48	Warm Handover or Connection Entity	Select the entity that was referred to the participant	(System will generate drop-down choices based on specific partners registered)	AN50
49	Employment Navigator Referral Source	Select the primary sources of how the participant heard about the Employment Navigator program. Select all that apply.	1 = DOL TAP Courses 2 = Social Media - Facebook 3 = Social Media - LinkedIn 4 = Social Media - Twitter 5 = Email/Text Notification 6 = Word of Mouth 7 = Warm Handover from Commander 8 = American Forces Network / Television 9 = Other	IN8
50	Placed into Employment	Indicate if the participant was placed into an employment opportunity as a result of Employment Navigator Services. Do not complete this field if participant is referred to a partner.	1 = Placed into employment 2 = Placed into an Apprenticeship program 3 = Not placed	IN1
51	Placement Location - State	Indicate the state in which the participant was placed into employment.	XX (state postal code)	AN2
52	Placement Location - City	If known, indicate the city in which the participant was placed into employment.	XXXXXXXX	AN50
53	Hourly Wage of Job Placement	If the participant was placed into employment or an Apprenticeship program, indicate the starting wages per hour	$XXX.XX	IN5
54	Other Notes	Optional field. Insert any notes on services provided that may assist other Employment Navigators or partners	XXXXXXX	AN500
55	Case Closed	Select the reason for participant case closure.	1 = Closed due to job placement or referral to partner 2 = Closed due to Participant no longer interested 3 = Closed due to participant inactivity of 90 days with no future services scheduled	IN1
56	Future Service Date	Select a future date at which the participant will receive additional Employment Navigator services. A value in this field will keep the participant record in 'open' status	YYYYMMDD	Date8
57	Special Project Identifier	Placeholder for any future enhancements to filter out participants based on a set criteria	XXXXX	AN5
Data Type Codes: AN = Alpha-Numeric; IN = Integer; Number behind code represents the overall length allowable for the field.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 0.25 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, 200 Constitution Ave., NW, Washington, DC 20210 or email murren.luke@dol.gov and reference the OMB Control Number 1293-0NEW.