Free 44713.FH11 - Indiana

INITIAL ASSESSMENT OF EMPLOYABILITY
State Form 44713 (R3 / 7-97) / IMP 2074

* The request for your Social Security number is MANDATORY and this assessment cannot be completed without it; according to SSA Sec. 4 (a) (2), FS Act of 1977 Sec. 16-E (a) (2). The information contained on this form shall be CONFIDENTIAL according to 470 IAC 1-2-7, 470 IAC 1-3-1 and 470 IAC 6-1-1.

Check one of the below: TANF-IMPACT 1. Name of participant *Social Security number FS-IMPACT

Check one of the below: TANF CONTROL TANF TREATMENT

Referred to:

Date (month, day, year)

County Birthdate (month, day, year) Telephone number ( )

Address (number and street, city, state, ZIP code) Case number 2. Do you: Ride a bus? Walk? Drive? Own a car? Have a driver's license? 3. Household Members: Case head Other income: Sex: Male Female

Name

Relationship to you

Birth Date

Current School or Employment

Does this person have any problems that will affect your work or school? If so, what are they?

4. (A) Employment History: Name of present or last employer Address (number and street, city, state, ZIP code) Date started (month,day, year) Date ended (month, day, year) Name of previous employer Address (number and street, city, state, ZIP code) Date started (month, day, year) Date ended (month, day, year) (B) Any additional employment information? Title / Duties Reason for leaving Title / Duties Reason for leaving Salary Salary

(C) Other work skills not listed above?

Page 1

5. Education: Circle the highest grade of school completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16+ Vocational Training (list type of training) If college, degree or area of study School: 6. Do you need training to get a job? Date completed Do you have: GED High School Diploma College Degree

7. What do you see yourself doing in 5 years?

8. Are you a veteran? Yes 9. A. Will you need help with child care costs? Yes No C. Do you have other problems that would keep you from getting a job? No

Honorable Discharge? Yes B. Will you need transportation costs? Yes No No

D. Barriers identified to employment (these can be noted at any time). Attach additional page(s) as needed.

Name of contact person Address (number and street, city, state, ZIP code) Telephone number

(

)

RELEASE I, the undersigned, agree to release information contained in this document, to any agency, school, or other organization, which the DFC shall deem appropriate for the development and implementation of my Initial Assessment of Employability. This release is valid for six months from the date below.
Signature of participant Name of participant Signature Name of agency * Social Security number Title Date (month, day, year) Date (month, day, year)

Page 2