Individual Worker Record Form Contact Information First Name Last Name Middle Name Date of Birth Last four digits of SSN Original Program Start Date Address Apt. # City State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip Code Home Phone Cell Phone Email Address Gender Male Female X — includes Trans, Non-Binary, Two-Spirit, and Binary people and people who don't want to disclose their gender identity Race / Ethnic Identity Native American or Alaskan Native African American/ African/ Afro-Caribbean Asian/ Pacific Islander or Native Hawaiian Latino or Hispanic White (not Latino/a) Other Specify Country of Birth Date of US Settlement Native Language Immigrant? Yes No Refugee? Yes No Employment Status Employed Full-Time Employed Part-Time Unemployed How long? Years Months Not available for employment Self–employed Received a-1099 Form for work Employer's Name Job Title Hourly Rate of Pay $ Work Location Marital Status Single Married Widowed Separated Divorced Number of Adults in the Household Number of Children (under 18) in the household Annual Household Income $0 - $14,999 $15,000 - $24.999 $25,000 - $34,999 $35,000 - $44,999 $45,000 - $54,999 $55,000 - $64,999 $65.000 - $74,999 $75,000+ Are you a veteran? Yes No Referral Source Workers Union Other, Specify Public Assistance Not receiving Public Assistance SNAP (EBT card) MEDICAID Section 8 Assistance TANF Supplemental Security Income (SSI) Old – aged Assistance Social Security Disability (SSD) Safety Net Aid to the Blind or Totally Disabled Other, Specify Case Number Are you collecting Unemployment Insurance Benefit? Yes No Educational Background Education Level Less than 12th Grade High School Diploma Post Secondary Education Other Specify Credential (Certifications and Licenses) Achieved in U.S. Are you Union Member/Family of Member? Yes No Member Family of member Union Affiliation Local School Aged Children Is the student the parent or guardian of children under the age of 21? Parent/Guardian Yes No Single Parent Yes No Enter the number of children at each level: Pre-School Elementary School Junior High School High School College Population Categories Homeless In Correctional Facility Other Institutionalized High School Graduates or Equivalent Displaced Homemakers Head of Household Disabled Enrolled in Other Education/Training Veterans Dislocated Workers Employed at 200% of Poverty Level Low Income NYCHA Resident Learning Disabled Non Native English Speaker Other Worker Goals Obtain a Job Retain Current Job Improve Current Job Enter Training Enter an Apprenticeship Program Earn High School Diploma Enter Post-Secondary Education Improve Basic Literacy Skills Improve English Literacy Skills Other, Specify Teacher Name Days of Class Time Form Completed By Date Submit