WSA Outreach Questionnaire

Name *

First

Middle

Last

Email *

Age *

Selective Service (Males 18 & Older)RegisteredNot Registered

Ethnicity

• Black (Non Hispanic)
• Hispanic/Latino
• White/Caucasian
• Asian/Pacific Islander
• Native American/Alaskan Native
• Other

If other (Please Specify)

Are you currently employed? *

• Yes
• No

Have you been laid off due to COVID-19?

• Yes
• No

• Currently Receiving Food Stamps
• Currently Receiving TANF
• Currently Receiving SSI (Supplemental Security Income)
• Household Income (Last 6 Months)

• Disability
• Basic Skills Deficiency
• Homeless/Runaway
• Single Parent (Pregnant Parenting)
• English Language Learner
• Offender
• Individual Facing Cultural Barriers
• Foster Care
• Resides in High Poverty Area
• Needs Additional Assistance to Complete School or Obtain Employment

Other Barrier

• Finding Job Leads
• Resume Building
• Interviewing Skills
• Education
• Identifying My Skills
• Job Interests
• Stress Management
• Improving My Skills
• Tips on Keeping A Job
• Job Application Assistance
• Goal Setting
• Childcare
• Job Aptitude
• Clothing
• Criminal Background/Bonding
• Explore Careers
• Transportation
• Learn About Wages
• Other

If other, please specify

Name Household Member 1

First

Middle

Last

Age Household Member 1

Relationship Household Member 1

Income Source Household Member 1

Name Household Member 2

First

Middle

Last

Age Household Member 2

Relationship Household Member 2

Income Source Household Member 2

Name Household Member 3

First

Middle

Last

Age Household Member 3

Relationship Household Member 3

Income Source Household Member 3

Name Household Member 4

First

Middle

Last

Age Household Member 4

Relationship Household Member 4

Income Household Member 4

Name Household member 5

First

Middle

Last

Age Household Member 5

Relationship Household Member 5

Income Source Household Member 5

Name Household Member 6

First

Middle

Last

Age Household Member 6

Relationship Household Member 6

Income Source Household Member 6

Name *

First

Middle

Last

Emergency Contact Relationship

Check Here if the information entered into this form is true. *

• The information provided is true

Submit