WIA Initial Questionnaire Name * First Date Address * City * State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Postal Code Home Phone * Cell Phone Email * Date of Birth * SNN * In order that we may identify eligibility for special services and funding please answer the following: Do you have a disability? * Yes No If Yes, choose one: Temporary Permanent This information is helpful in supplying customer needs; however, you are not required to provide an answer. Are you employed? Yes No Last or current employment: Where Hrs / Week Wage If not employed Terminated Quit Laid Off Never Worked Are you currently receiving Unemployment Insurance Benefits? Yes No Previous six months income for you and your spouse Numberof family members living in the household Household sources of income: (select all that apply) Salary/Wages Unemployment Insurance Pension Social Security Public Aid Food Stamps Child Support Supplemental Security Income (SSI) School Grants Other Are you currently registered with Illinois Skills Match Yes No Where When Where When What Skills do you have? What Interests and/or hobbies? Why has it been difficult for you to secure amployment? Are you being assisted by any other agency? Yes No If yes, which? Do you have a high school diploma? Yes No GED? Yes No Are you currently attending? (select all that apply) High School GED Classes Alternative School College Vocational School Do you have any valid degrees? Yes No Certificates? Yes No Licenses? Yes No If yes, what are they? Are you in default of a student loan? Yes No Are you on academic probation? Yes No Course of Study Have you contacted school of your choice? Yes No Have you been accepted into an educational program? Yes No If yes, what program? Have you been accepted into an educational program? Yes No How many credit hours? Have you applied for federal financial aid? (WIA Requirement) Yes No Do you have an award or denial letter for federal financial aid? Yes No Are you a former Workforce Investment customer? Yes No PLEASE NOTE THAT ALL INFORMATION GIVEN IS CONFIDENTIAL. reCAPTCHA If you are human, leave this field blank.