WSA Outreach Questionnaire | WorkSource Atlanta : WorkSource Atlanta

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Cell Phone *

Other Phone

Date of Birth *

Age *

Selective Service (Males 18 & Older)

Ethnicity

If other (Please Specify)

Employment

(Check All That Apply)

Are you currently employed? *

Yes
No

Have you been laid off due to COVID-19?

Yes
No

Income

(Check All That Apply)

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

Barriers

(Check All That Apply)

Other Barrier

Services Needed

(Check All That Apply)

If other, please specify

Household Information

Please provide information about people living in your household.

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

Emergency Contact

Name *

First

Middle

Last

Emergency Contact Relationship

Emergency Contact Phone

Agreement

I hereby certify that the information above is true and accurate. I allow release of this information for verification purposes and understand that it is used for eligibility. I understand that if the above information is misrepresented, it will be grounds for termination from program.

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

The information provided is true