Supplemental Questionnaire
Additional Information & Program Eligibility

Please answer these questions to help us determine if you qualify for other Workforce System programs and services.  This information is confidential and will only be used to determine further program eligibility, federal reporting requirements for Workforce Innovation and Opportunity Act - funded programs, and affirmative action requirements.  We would like you to complete this form so we can help you better.  However, answers are voluntary.

1.  Are you or any member of your family receiving any Public Assistance/Low Income?

2.  Are you a person with a disability?

3.  Are you a migrant or Seasonal Farm Worker?

4.  Are you a spouse of a US Armed forces member on active duty and lost your job as a direct result of relocation due to a permanent change in your spouse's duty station?

5.  Are you a Displaced Homemaker?

Have you been providing unpaid services to family members in the home and:

  • Depended on the income of another family member but are no longer supported by that income, or are the dependent spouse of a member of the military on active duty and whose family income is significantly reduced due to a deployment, a call or order to active duty, or the death or disability of the member, AND

  • Are unemployed or underemployed and are having trouble finding or keeping employment.

7.  Are you homeless?

8.  Are you an ex-offender?

Were you subject to any stage of the criminal justice process?  Do you need help overcoming barriers to employment resulting from a record of arrest or conviction for crimes against persons or property, status offenses or other crimes.

9.  Are you an English Language Learner?

Do you have limited ability in speaking, reading, writing or understanding English?  Do you meet one of the following two conditions?

  • Is your native language a language other than English?

  • Do you live in a family or community where a language other than English is the main language?

10.  Do you think you have a cultural barrier?

Do you have attitudes, beliefs, customs or practices that may make it hard for you to find work?

11.  Do you lack basic skills?

Are you unable to solve problems, or read, write, or speak English at a level necessary to function on the job, in your family, or in society?

I certify that the information given on this document is true and accurate to the best of my knowledge

The Workforce Innovation and Opportunity Act financially assisted program is an equal opportunity employer / program. Auxiliary aids and services are available upon request to individuals with disabilities. To request reasonable accommodation, please call Maria Lombardi at (516) 485-5000 ext. 1113.

Supplemental Questionnaire
Additional Information & Program Eligibility

Please answer these questions to help us determine if you qualify for other Workforce System programs and services.  This information is confidential and will only be used to determine further program eligibility, federal reporting requirements for Workforce Innovation and Opportunity Act - funded programs, and affirmative action requirements.  We would like you to complete this form so we can help you better.  However, answers are voluntary.

1.  Are you or any member of your family receiving any Public Assistance/Low Income?

Check all that apply:

Low income individual with a total family income that does not exceed the higher of:

2.  Are you a person with a disability?

Do you have a physical or mental impairment that substantially limits oe or more of your major life activities?

If Yes, do you have a:

3.  Are you a migrant or Seasonal Farm Worker?

If "Yes," check one of he following:

4.  Are you a spouse of a US Armed forces member on active duty and lost your job as a direct result of relocation due to a permanent change in your spouse's duty station?

5.  Are you a Displaced Homemaker?

Have you been providing unpaid services to family members in the home and:

  • Depended on the income of another family member but are no longer supported by that income, or are the dependent spouse of a member of the military on active duty and whose family income is significantly reduced due to a deployment, a call or order to active duty, or the death or disability of the member, AND

  • Are unemployed or underemployed and are having trouble finding or keeping employment.

6.  Are you a single parent?

Are you a single, separated, divorced or widowed person who has primary responsibility for one or more dependent children under age 18 (including single pregnant women)?

7.  Are you homeless?

Do you lack a permanent and suitable nighttime residence?  This includes:

  • Sharing housing with other persons due to loss of housing, economic hardship or a similar reason

  • Living in a motel, hotel, trailer park or campground due to a lack of other suitable options

  • Living in an emergency or temporary shelter

  • Abandoned in a hospital

  • Awaiting foster care placement, or

  • Having a main nighttime residence that is a public or private place such as a car, park, abandoned building, bus or train station, airport or campground.

8.  Are you an ex-offender?

Were you subject to any stage of the criminal justice process?  Do you need help overcoming barriers to employment resulting from a record of arrest or conviction for crimes against persons or property, status offenses or other crimes.

9.  Are you an English Language Learner?

Do you have limited ability in speaking, reading, writing or understanding English?  Do you meet one of the following two conditions?

  • Is your native language a language other than English?

  • Do you live in a family or community where a language other than English is the main language?

10.  Do you think you have a cultural barrier?

Do you have attitudes, beliefs, customs or practices that may make it hard for you to find work?

11.  Do you lack basic skills?

Are you unable to solve problems, or read, write, or speak English at a level necessary to function on the job, in your family, or in society?

I certify that the information given on this document is true and accurate to the best of my knowledge

The Workforce Innovation and Opportunity Act financially assisted program is an equal opportunity employer / program. Auxiliary aids and services are available upon request to individuals with disabilities. To request reasonable accommodation, please call Maria Lombardi at (516) 485-5000 ext. 1113.