SCSEP Participant Form Checklist

If one or more are checked under Definition, then the definition has been met, unless otherwise noted. If one or more are checked under Validation, then the documentation is acceptable.

Criteria Definition Validation Chose at least one Homeless  Lack of a fixed, regular nighttime residence  Official Document - Letter or  Nighttime residence consists of: statement from the director of a  Temporary living accommodations (Hotel/Motel, shelter or institution, social Shelter, etc.) agency, VA, etc.  Institution  Case Note - Details on living  Public or private place not designed or used for condition and how that human occupancy determination was made  Self or Third Party Attestation At Risk of  Lack of resources and supports needed for housing  Eviction Notice, letter from a Homelessness  Living at or below poverty level shelter etc. (Requires two in  Currently lives in housing that is associated with  Case Note - Detail what meets the Definition to homelessness not paid for by a governmental program definition and how the qualify)  Exiting a publicly funded institution or system of care determination was made  Fixed income with cost of living increases (rent, (rent/mortgage unpaid or due, healthcare, etc.) taxes unpaid, credit history, unpaid bills, and etc.)  Self or Third Party Attestation Limited  Does not speak English at home or with family and friends  Official Document - Literacy Test English  Cannot read, speak, write or understand English results, standardized test results, Proficiency  Identified by Language Identification Flashcard (LIF) and etc. (LEP) (attached)  Case Notes - Detail what meets the  A translator confirmed LEP definition and how the determination was made (LIF, interpreter and case worker assessment) Page 1 of 7  Self or Third Party Attestation

Criteria Definition Validation Chose at least one

Low Literacy  Participant is at or below an 8th grade reading level  Official Document – Results from Skills literacy testing, standardized testing, etc.  Case Notes - Explain in detail  The participant has low literacy skills  How that assessment was made  The date that assessment was made  Self or Third Party Attestation Displaced Homemaker  Provided unpaid services to family  Employment History members in the home  Case Notes - Detail should include  Dependent on the income of  When family members were another family member but is no provided unpaid services longer supported by them  Why the dependent income  Unemployed or underemployed is no longer supportive  Low employment history Frail  Is unable to perform at least two  Official statement by qualified activities of daily living without medical professional or certification substantial human assistance that: including verbal reminding,  A qualified professional physical cueing, or supervision determined frailty  Describes how the Page 2 of 7 disability meets the definition, including medical records, physician’s statement, psychologist’s diagnosis and etc.  Official statement is not used -  Case Notes - Detail about how the definition is met and use supportive documents (Social Security records, school record social service records, and etc.) Criteria Definition Validation Chose at least one Veteran  Served in the active U.S. military, Official government document naval, or air service and who was verifying status – (one or more) discharged or released from such  Military discharge papers, service under conditions other than DD 214 dishonorable.  Cross-match with Veteran’s Database  Copy of military ID along with official notice from the Department of Veteran’s Affairs Case Notes - A veteran discharged prior to 1950 must be noted as  Veteran status including branch served, approximate dates of service and how that determination was made Page 3 of 7 Self-Attestation ONLY for veteran’s discharged prior to 1950.

Failed to Find Employment Using  Utilized services but did not enter  Official Document from WIA WIA Title I employment personnel  Case Notes - Detail must include  When services were utilized  Why employment was not entered  Dates when services were utilized

Criteria Definition Validation Chose at least one Low  will not obtain employment without the assistance of the  Official government records, Employment SCSEP or another workforce development program medical records or other official Prospects/  Has significant barriers (must check one to qualify) records that establishes one or Severely  Lacking a substantial employment history more barriers including receipt of Limited  Basic skills, and/or English-language proficiency SSDI, school records, literacy tests Employment  Lacking a high school diploma or equivalent and etc. Prospects  Having a disability  Case Notes - Detail must include (Requires one  Homeless  Participant has one or more or more in  Residing in a socially and economically isolated barriers definitions to rural or urban area.  How the determination was qualify) made  Source of the information

of 7  Contact at the source  Date the information was obtained  Self-Attestation - Must specifically explain why the attester’s situation meets the definition Persistent  Annual average unemployment rate for a county or city is  Official government records, Unemployment more than 20 percent higher than the national average for medical records or other official two out of the last three years records that establishes one or more barriers including receipt of SSDI, school records, literacy tests and etc.  Established area of unemployment  Case Notes - Detail must include  Description of each barrier  How it was determined it was a barrier  Established area of unemployment  Self-Attestation - Must include specific information explaining why the attester’s situation can be considered under the definition Criteria Definition Validation Chose at least one Disability Participant must be informed that  Official documents indicating (Voluntary information), this information is voluntary.  A medical professional Refusal to answer will have no made a determination of a effect on any decision to provide disability services.  Describes how the

of 7  Mental or physical condition or determination meets the combination of, that results in definition and can include limitations on mobility, learning, SSDI, social service agency self-care, self-direction, emotional record or referral, adjustment, capacity for independent Living Center independent living, cognitive statement and etc. function (awareness) and language (not LEP)  Participant is impaired at time of enrollment  Receives Social Security Disability Severe Disability Participant must be informed that  Official documents indicating (Voluntary Information) this information is voluntary.  A medical professional Refusal to answer will have no made a determination of a effect on any decision to provide disability services.  Describes how the  Severe, chronic disability to mental determination meets the or physical impairment that is likely definition and can include to: SSDI, social service agency  Continue indefinitely record or referral,  Result in limitation to three independent Living Center or more area of major life statement and etc. activity such as self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, economic self-sufficiency  Participant is impaired at time of enrollment

of 7 Criteria Definition Validation Chose at least one Rural  An area not designated as a metropolitan statistical area  Documentation that the Rural by the Census Urban Commuting Area (RUCA) Zip code database in SPARQ was utilized Age 75 or  At time of intake participants age is 75 years or older  Official government record that older verifies the participant’s date of birth including birth certificate, driver’s license, passport and etc.