ALASKA TEMPORARY ASSISTANCE PROGRAM
EMPLOYMENT PLANNING INFORMATION
This form will help collect information about your employment goals, interests, work background, education and personal history so that you are better able to get, keep and advance in a job.
Name: Date of Birth: Date: Address: City: State: Home Phone: Cell Phone: Is English your first language? Yes No If ‘no’, what is?
EMPLOYMENT HISTORY
1. Have you worked in the past? Yes _____ No ______
2. Have you held a job for longer than six months? Yes _____ No ______(If no, skip to question #3) a) If yes, was it: full time ______part time ______seasonal ______temporary ______b) What type of job was it? ______Date ended: ______
3. Are you working now? Yes ____ No ____ If yes, what type of work are you doing? ______
4. What have you been doing to find work? ______
5. My past supervisor liked my work: a) all of the time ___ b) some of the time ___ c) never ____ I like my work group to be: a) small ___ b) large ___ c) self-describe:______
6. Were you able to learn and perform your job with little or no supervision? Yes _____ No _____
7. Do you consider yourself successful in your previous jobs? Yes ___ No ___ Please explain:
8. In your previous jobs, did you receive positive feedback from your supervisor? Yes _____ No _____
9. In your previous jobs did you receive pay raises or increased level of responsibility? Yes ______No______
Page 1 of 6 TA 5 (06-3871) rev 6/12 10. If asked, what would a former supervisor, co-worker or customer say about your strengths? Please describe:
11. If you were offered a job tomorrow could you accept it? Yes ____ No ____ If no, please explain:
WORK SKILLS & EXPERIENCE
Please provide an overview of your paid work and volunteer experience. List the type of work (for example, child care, clerical, fishing), the total amount of time you have done the work, and the number of different employers for whom you have done the work.
Type of work Total months of this Total number of employers type of work for this type of work
SKILLS AND KNOWLEDGE
1. List equipment, machinery and tools you can operate:
2. Do you have computer skills? Yes ___ No ___ List what computer applications you can use? (i.e., MSWord, Excel, Social Media, etc.)
3. Do you have keyboarding skills? Yes ____ No ____ WPM ______Can you operate at 10-Key machine? Yes ____ No ____
4. Have you used a computer to fill out a job application? Yes____ No ____
5. Do you have access to a computer to fill out a job application? Yes ____ No _____
6. Do you know where to go to get access to a computer? Yes ____ No ____ 7. List any other skills or abilities you have that can help you find and keep a job:
8. List any licenses or certificates you hold:
9. Do you have a valid Alaska Driver’s License? Yes ____ No ____ Driver’s License # ______
a. Do you have a vehicle? Yes____ No ____
b. If yes, is the vehicle in working order? Yes____ No ____ If no, explain what needs to be fixed:
c. Does the vehicle have insurance? Yes____ No ____
d. Do other people in the household also use the same vehicle? Yes____ No ____
e. Do you live within walking distance to a bus stop? Yes____ No ____
10. Are you registered with the Alaska Employment Service ALEXSYS system? Yes ____ No ____ Date of Registration: ______
11. Do you have a resume? Yes ____ No ____ If yes, please attach a copy.
12. Do you need help writing a resume? Yes ____ No ____
13. What do you think your challenges are to getting a job?
14. What other help do you need to go to work?
15. Have you applied for or interviewed for a job within the past 30 days? Yes ____ No ____ Where:______
EDUCATION & TRAINING
1. Circle the highest grade you’ve completed.
1 2 3 4 5 6 7 8 9 10 11 12 GED Post Secondary education: ______
Page 3 of 6 TA 5 (06-3871) rev 6/12 2. Did you have an Individual Education Plan (IEP) or did you require assistance with your classes when completing middle school or high school? Yes ____ No ____ If yes, please explain:
3. What were your strongest interests in school? ______
4. What was your favorite class and why?
5. Describe your learning style. Are you: Visual (see it) _____ Auditory (hear it) _____ Kinesthetic (do it) _____
6. Have you started any college courses or vocational training programs? Yes __ No ___ Where:______Course of study:
Number of months attended: Did you complete the course: Yes ______No ___
7. Are you currently in school or training? Yes ____ No ____ Where: ______
Course of study:______
FUTURE WORK
1. What type of work would you like to be doing?
2. Do you know of any job openings in this line of work? Yes ____ No ____ Where? ______
3. Have you ever taken a career interest inventory to help identify your strongest job interests? Yes ____ No ____
4. Are you willing to move to look for or accept a job? Yes ____ No ____ 5. Who are your work references? Name Relationship (i.e., friend, co-worker, supervisor)
ADDITIONAL INFORMATION
1. Are you a Military Veteran? Yes ____ No ____ a. If yes, dates of service: ______to ______b. Branch of service: ______c. Type of discharge: ______
2. Do you have a past conviction or pending charges? Yes ____ No ____ If yes, please explain:
3. Do you have any legal issues that impact your ability to work? Yes ____ No ____ If yes, please explain:
PERSONAL HISTORY
4. List all persons in your household at this time.
Name Relationship Age Living In the Home Living Outside the Home
5. Is there anyone in your household who is dependent on you for their care? Yes ____ No ____ Who? ______For what purpose? ______Daily care? ______Occasional Care? ______Other______
6. Is there anyone who does not live in your household who is dependent on your care?
Page 5 of 6 TA 5 (06-3871) rev 6/12 Yes ____ No ____ Who? ______For what purpose? ______Daily care? ______Occasional Care? ______Other______
7. What other agencies are helping you and your family? Please check all that apply:
Housing Assistance Office of Children’s Services Behavioral / Mental Health Adult Basic Ed Dept. of Corrections / Probation Childcare Resources Vocational Rehabilitation WIA / Job Training Substance Abuse Counseling Domestic Violence Shelter Tribal Agency Juvenile Justice Health / Medical Providers Special Education Other:
8. Are you and your family safe at home? Yes ____ No ____
9. Have you ever been afraid of anyone in your household? Yes ____ No ____
10. Have you or a family member had a traumatic injury, substance abuse issue or any other medical issues that have kept you from working? Yes ____ No ____ If yes, explain:
11. Do you and your family have your monthly basic needs and expenses covered? Yes ____ No ____ If no, please indicate what you may need assistance with (check all that apply): Rent / Food Electrici Clothin Health Housing ty / Fuel g Care Oil Other:
12. Please list any items you would like to discuss or questions you may have that have not been addressed in this document:
Client Signature: Date:
Thank You