CNA or CDL Rapid Workforce Training Application

Section 1 CONTACT INFORMATION

Are you a Delaware Resident?

Yes No

Were you economically injured as a result of the Covid-19 pandemic?

Yes No

Were you laid off as a result due to the COVID-19 pandemic?

Yes No N/A

Are you unemployed as a result due to COVID-19 pandemic?

Yes No N/A

First Name:

MI:

Last Name:

Email:

Password:

Full SSN:

Primary Phone:

Alternate Phone:

Physical Address:

City:

State:

Zip:

Use Current Address for Mail Address:

Mail Address:

Physical Address:

City:

State:

Zip:

Alternative Contact Name:

Alternate Contact Home Phone:

Section 2 DEMOGRAPHIC INFORMATION

Date of Birth:

Gender:

Male Female Did not self-identify

Age:

Selective Service: (For males 18 years or older)

Registered Not Registered Documented Exception Not Applicable

Authorization to Work/U.S. Citizenship:

U.S. Citizen Permanent Resident Alien/Refugee lawfully Permanent to U.S. with right to work

If alien/refugee-provide Alien/Visa registration number:

Visa Expiration Date:

Considered to be of Haitian Heritage:

Yes No

Considered to be of Hispanic Heritage:

Yes No

Race - Ethnicity: (Check all that apply):

African American

America Indian/Alaskan Native

Asian

Hawaiian/Other Pacific Islander

White

Do not wish to answer

Section 3 DISABILITY INFORMATION

Considered to have a disability:

Yes No Participant did not self-identify

Received Services from a State Development Disabilities Agency (SDDA):

SDDA No

Received Services from a State or Local Mental Health Agency (LSMHA):

LSMHA No Unknown

Received Services from a Home & Community Based Service Provider under a State Medicaid (HCBS) Waiver:

HCBS Waiver No Unknown

Disability Work Setting:

N/A Competitive Integrated Employment Individual Supported Employment Group Supported Employment Sheltered Workshop Combination of two or more settings Not Employed Unknown

APPLICANT

First Name:

Last Name:

ALast 4 of SSN:

DISABILITY INFORMATION (Continued)

Type of Customized Employment Services Received:

Discovery assessment services

Employer negotiation Services

Developed a customized employment search plan

Employment by customized services & extended support servicesn

No CES services

Unknown

Received Disability Financial Capability:

N/A

Benefit planning services

Financial capability/asset development services

Benefit planning services and financial capability/asset development services

Unknown

Section 4 VETERAN INFORMATION

Eligible Veteran Status:

Yes, <= 180 days* Yes, Eligible Veteran* Yes, Other Eligible Person** No If No, proceed to Section 5)

Disabled Veteran:

Yes, Disabled Yes, Special Disabled (30%) No

Homeless Veteran:

Yes No

Category of Disability:

Physical/ Chronic Health Condition

Physical/Mobility Impairment

Mental or Psychiatric

Vision Related

Hearing-related

Learning

Cognitive/ Intellectual

Section 5 EMPLOYMENT STATUS

Employment Status:

Employed Not Employed Employed, but received notice of termination of employment or military separation

If Employed, Individual is Underemployed:

Yes No N/A

Reemployment Assistance Recipient:

Yes No N/A

Number of weeks unemployed?:

Current or most recent hourly rate of pay: $

Current/Recent ONET Job title:

Click Here to search ONET Job title

APPLICANT

First Name:

Last Name:

ALast 4 of SSN:

DISLOCATED WORKER INFORMATION (Answer only if DW)

Employment Status at Dislocated Worker Eligibility:

Employed Employed, but received notice of employment or military separation Not Employed

Under-Employed at Dislocated Workers Eligibility:

Yes No

Section 6 EMPLOYER DISLOCATION (Answer all applicable questions)

Projected Layoff Date:

Actual Layoff Date (Leave blank if date is in the future):

Employer at Layoff:

Employer Address:

City:

State:

Zip:

Dislocation Hourly Wage $:

Number of weeks unemployed:

APPLICANT

First Name:

Last Name:

ALast 4 of SSN:

Section 7 EDUCATION STATUS

School Status:

In-School; secondary or less In-School; post-secondary school Not attending school or secondary school Dropout Not attending school; Graduate Not attending school, within age of compulsory attendance Attending Alternate School

Section 8 PUBLIC ASSISTANCE

Are you or a family member currently receiving Temporary Assistance for Needy Families (TANF):

Yes No

TANF Recipient:

Self Family Member Not Applicable

Are you or a family member receiving Supplemental Security Income or have received in the past six months:(SSI):

Yes No

SSI Recipient:

Self Family Member Not Applicable

Are you receiving General Assistance (GA):

Yes No

GA Recipient:

Self Family Member

Are you or a family member receiving Supplemental Nutrition Assistance Program (SNAP) or have received in the past 6 months:

Yes No

SNAP Recipient:

Self Family Member Not Applicable

Are you receiving services from WIOA Adult, Dislocated Worker, or Youth:

Yes No

RCA Recipient:

Self Family Member

PUBLIC ASSISTANCE (Ages 16-24 Only)

Living in a high-Poverty:

Yes No

Section 9 INDIVIDUAL BARRIERS

Homeless:

Yes No

Out:

No N/A

Ex-Offender:

Yes No Did not self-identify

APPLICANT

First Name:

Last Name:

ALast 4 of SSN:

BARRIERS TO EMPLOYMENT

Section 10 FAMILY INCOME

Family Size:

Family Income:

Current LLSIL based on family size: $

Self-Attestation:

APPLICANT ATTESTATION: I certify, by my signature, that I have read and acknowledged the information on this form is true and accurate. I further understand the above information, if misrepresented or incomplete may be grounds for termination and/or penalty as specified by law. Information is being provided to establish eligibility for services under the Rapid Response Recovery Program and is subject to all applicable Federal and State confidentiality laws.

Applicant Printed Name

Applicant Signature

Date

CSTB Staff Printed Name

CSTB Staff Signature

Date

CNA or CDL Rapid Workforce Training Application

Section 1

CONTACT INFORMATION

Mail Address:

Section 2

DEMOGRAPHIC INFORMATION

Section 3

DISABILITY INFORMATION

APPLICANT

Section 3

DISABILITY INFORMATION (Continued)

Section 4

VETERAN INFORMATION

Section 5

Section 5

EMPLOYMENT STATUS

APPLICANT

Section 6

DISLOCATED WORKER INFORMATION (Answer only if DW)

Section 6

EMPLOYER DISLOCATION (Answer all applicable questions)

APPLICANT

Section 7

EDUCATION STATUS

Section 8

PUBLIC ASSISTANCE

Section 11b

PUBLIC ASSISTANCE (Ages 16-24 Only)

Section 9

INDIVIDUAL BARRIERS

APPLICANT

Section 13

BARRIERS TO EMPLOYMENT

Section 10

FAMILY INCOME