WIOA Initial Questionnaire WIOA Initial Questionnaire Name * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Home Phone * Email * Date of Birth * Are you between the ages of 17-24 years? * Yes No Are you an individual with a disability? * Yes No Under the ages 17-24 Are you currently attending: (Check all that apply) High School GED classes Alternative School College Vocational School None of the above Do you have a high school diploma? * Yes No Do you have a GED? * Yes No Do you or did you have an IEP? * Yes No If you attend high school, are you receiving free/reduced lunches? * Yes No Are you an individual with a disability? * Yes No Is English a second language for you? * Yes No Are you subject to the juvenile or adult justice system? * Yes No Are you pregnant or parenting? * Yes No Are you: (check all that apply) Homeless Runaway In foster care/aged out Above the ages 17-24 Are you currently employed? * Yes No Where are you employed? * How many hours per week do you work? * Wage * Are you currently receiving Unemployment Insurance Benefits? * Yes No Are you currently registered with the Illinois Skills Match? * Yes No Why? * Why not? * Are you being assisted by any other agency? * Yes No Do you have a high school diploma? * Yes No Do you have any other valid degrees or certificates? * Yes No What degree or certificate? * Do you have any valid licenses? * Yes No What licenses? * Are you receiving SNAP/TANF benefits? * SNAP TANF Both None of the Above Are you seeking assistance while job seeking? * Yes No Are you a former Workforce Investment customer? * Yes No Current and future education plans Please select the highest grade completed: * 123456789101112 – no HS Diploma12- HS diplomaGEDFreshman- collegeSophomore- collegeJunior- collegeSenior- collegeAssociate degreeBachelor’s degreeMaster’s degreeDoctorateAttained certificate of attendance/completionAttained other post high school degree or certificate Are you in default of a student loan? * Yes No Are you on academic probation? * Yes No Do you have an award of or denial letter for federal financial aid? * Yes No Are you currently enrolled in college/trade school? * Yes No Name and location of school * Program you are enrolled in * Start Date * Expected completion date * Have you contacted the school of your choice? * Yes No Have you been accepted into an educational program? * Yes No Name of program * School name and location * Expected Start Date * Expected end date * Are you wanting assistance with tuition, books, and fees to begin a new training program? * Yes No Have you applied for financial aid? * Yes No Employment Are you currently employed? * Yes No Name of current employer * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Your Position * Start Date * End date or expected end date Hours per week * Wage * If not employed: (please check one) * Terminated Quit Laid off Never worked Are you receiving Unemployment Insurance Benefits: (check one) * Yes No Pending Are you actively looking for work? * Yes No Has it been difficult to secure employment? * Yes No Why? * Why not? * What skills do you have? * Income Number of family members living in your household * Previous six-month income for your household * $ Household sources of income: (please select one) * Salary/wagesUnemployment insurancePensionSocial SecurityPublic aidSNAP Food stampsTANFChild supportSupplemental Security Income (SSI)School GrantsFree or reduced lunch (if in school)Other What is 2+3? Just making sure you are human and not a robot. Submit If you are human, leave this field blank.
