Operation Good Jobs Program Participation | Palmetto Goodwill

Operation Good Jobs Program Participation

OPERATION GOODJOBS PROGRAM DISCLAIMER FORM

    This program requires the active participation and communication of the enrolled participant for up to 12 months after the start date of employment. This means timely completion of requested documents, attendance at employment events, participation in financial education awareness activities, keeping a job log, regular email or phone contact with program staff, as well as keeping up-to-date personal contact information on file.

    Program Requirements

    I will actively participate in program activities and will actively communicate with program staff

    I understand failure to follow through on the requested program activities without communication with program staff and will result in dismissal from the program.

    I understand that while information provided will be kept confidential, it will be entered into the program management database. Additionally, that this information will not be shared with third parties without written consent.

    I hereby knowingly and voluntarily consent to the disclosure and exchange at any records or information pertaining to my employment verification.

    Media Release

    I hereby grant Palmetto Goodwill the right and permission to use Tangible and intangible items for any lawful, non-commercial purpose and in any and oil media without payment or any other consideration

    In addition, I waive any right to inspect or approve the finished product wherein my likeness appears.

    I hereby acknowledge that Palmetto Goodwill may grant the same permissions as set forth in this Consent and Release Form to Goodwill Industries International. Inc. (“GII“) and Palmetto Warrior Connection under the same terms and conditions

    This Consent and Release Form shall remain In effect for a period of five years, unless revoked. I understand that I may revoke this consent by submitting a written request. I understand that if l revoke this consent, my revocation will not have any effect on actions already taken by Palmetto Goodwill in reliance on my consent.

    I have voluntarily enrolled in the Operation GoodJobs Program and by signing below, I certify that I have read and understood this program disclaimer. l have been given the opportunity to have my questions answered, and I have been informed that Palmetto Goodwill must give me a copy of this document once it is signed.

    _____________________________________________

    INDIVIDUAL CAREER & FINANCIAL PLAN (ICFP) FORM

      Description of the Plan

      Your Individual Career and Financial Plan (ICFP) will help you plan your goals and work toward them with assistance from the Operation: GoodJobs Team. First, your plan will outline any obstacles you may be encountering in obtaining or maintaining employment. Second, your plan will outline your strengths, aptitudes, and abilities, and finally, your plan will include your overall goal(s) and the steps you plan to take to achieve them considering your strengths to manage the obstacles to obtaining or retaining employment.

      All information provided in this document will be kept CONFIDENTIAL. We will disclose protected information only as required by federal law in instances involving possible victims of physical assault, neglect, financial exploitation, rape or sexual molestation, and domestic abuses of elders, spouses, partners, or children.

      Why do l need this Program?

      Are you currently unemployed?

      YesNo

      If yes, for how long?

      01 – 12 weeks13 - 26 weeksmore than 26 weeks

      If no, how many hours per week do you work, and what is your rate of pay?

      What is your primary reason(s) for participating in Operation: GoodJobs?

      Find employment (full-time, part-time, temporary).Find a better job (career advancement).Further my education (GED, College courses, OtherBetter financial awareness.Help my family's future.

      Why do you wish to enroll in Operation: Good Jobs?

      Concerns

      What concerns do you feel hinder your ability to maintain a job or advance in your current position?

      ChildcareTransportationEducationLegal IssuesFinancialSpecial AccommodationPublic Assistance

      Childcare: Do you have children?

      YesNo

      Do you need assistance in finding reliable childcare?

      YesNo

      Transportation

      What is your primary mode of transportation?

      Own vehicleWalkBicycleBusFriend/Relative

      Do you have a valid driver's license?

      YesNo

      Do you have a valid CDL?

      YesNo

      Do you need assistance obtaining a license?

      YesNo

      Do you own a car?

      YesNo

      Legal Information

      Have you ever been convicted of a felony?

      YesNo

      If yes, what years, and what were your conviction(s):

      Do you have any outstanding warrants?

      YesNo

      Are you currently on probation/parole?

      YesNo

      Special Accomodations

      Do you have documented disability that prevents you from working?

      YesNo

      If yes, please explain:

      Do you have any health issues that prevents you from working?

      YesNo

      If yes, please explain:

      Are there any additional needs or accommodations that you require to go to work?

      YesNo

      If yes, please explain:

      Strengths

      List degrees and/or certificates. Please include school and graduation year:

      Are you interested in other training classes? If so, please describe.

      Financials

      Check the box by each statement that applies to you. Please be as truthful as possible.

      I know exactly how much total debt I haveI calculate my net worth (total assets minus total debts) annuallyI have an emergency saving account with at least $600 in itI have a written budget or spending planI have written financial goals with a date and dollar amount (ex: $1,000 for new computer by Jan '16)I have enough money each month to pay my rent or mortgage payment and all other household billsI plan for expenses that only come up once or twice a yearI have adequate life insuranceI have homeowners or renters' insuranceI pay my credit cards in full each monthI know the interest rate on all my credit cardsl am saving for retirementI have a will and advance medical directivesI always pay my bills on time and do not have any late payments on my creditI have reviewed my credit report within the last yearI know my credit scoreI comparison shop for services and major purchases by checking at least three sourcesI have never used a payday or title loanI have a checking accountI keep organized financial records and can find important documents easily

      Financial Fitness Level - Count up the number of checkmarks to get your score. If you scored 16-20, you are doing a great job and are above average in managing your finances. If you scored 11 - 15, you are doing a fair job of managing finances and have taken some steps in the right direction. If you scored 6 - 10, you are headed for financial difficulty. Now is the time to act and get back on track. If you scored 0 - 5, you need lots of help, but don't worry! It is never too late to take steps to improve your finances.

      Acknowledgement

      I participated in the development of this plan. I understand that this is my plan and the goals outlined in the plan are mine. I may at any time choose to make changes to my plan. I understand that the Operation: GoodJobs Staff will review my plan periodically. The staff may make recommendations for updates and modifications to my plan so that I may achieve my goals, but it is my responsibility to uphold the responsibilities outlined in my plan and to work with the Operation: GoodJobs Staff and my support system to attain success. I understand that this program is a minimum one-year agreement and I will maintain a working relationship throughout this time. My signature below indicates that I have received a copy of my plan and that I agree to work towards the goals that I have outlined.

      _____________________________________________

      MISSION IMPACT MEASURES REGISTRATION

        Please Tell Us About Yourself

        Race

        Ethnicity

        Hispanic/LatinoNot Hispanic/Latino

        Is Primary Language Spanish?

        YesNo

        Veteran/Person With Military History?

        YesNo

        Are You Are Veteran With A Disability?

        YesNo

        If Yes, Is It A Service Connected Disability?

        YesNo

        Are You A Member Of A Military Family?

        YesNo

        Are You A Caregiver For A Veteran?

        YesNo

        Post 9/11 Veteran?

        YesNo

        Education (Highest Grade Completed)

        None1-4th Grade5-8th Grade9-12th GradeGEDHigh School DiplomaAssociates DegreeBachelors DegreeGraduate DegreePostsecondary Credential

        Do You Identifiy With?

        History Of Substance AbuseUnemployedDislocated WorkerIncumbent Worker Underemployed/Working PoorCriminal BackgroundImmigrant RefugeeLGBTQNo TransportationHomelessLack Of Child Care Services

        Are You Currently Enrolled In?

        High SchoolPostsecondary Non-Degree AwardGraduate DegreeGED/HS EquivalencyAssociate Degree

        Disabilities

        No DisabilitiesBlindness Or Other Visual ImpairmentLearning Disability Other Than AutismDeafness Or Hard Of HearingDevelopmental DisabilityPsychiatric DisabilityNeurological DisabilityEmotional DisabilityAutismOther Disabling ConditionOther Physical Disability

        Who Referred You To Us Today?

        Walk In/Self ReferralEmployersState Agency For The BlindAdult Corrections Or Justice SystemJuvenile Justice SystemPostsecondary School/Community CollegesDept Of Defense Or Military Sevice AgencyVet Affairs Or Services AgenciesHomeless ShelterSNAP AdministrationTANF AdministrationWIOASSAState Voc Rehab AgencyElementary/Middle/High SchoolsOther Public Health, Human Or Social Service, Faith Based OrgMental Health Agency

        Work and Skills Progression

        Do you have any additional current certifications?
        If yes, please list all:

        Have you completed any of the following trainings (check all that apply)?

        Work ReadinessWork KeysComputer ClassesFinancial LiteracyOther

        Financial Wellness

        Are you receiving any of the following benefits or income supports (please check all that apply):

        Child Care SubsidyEarned Income Tax CreditFree or Reduced LunchHead StartLIHEAP (utility bill assistance)MedicaidRental Housing Assistance/subsidySNAP (food assistance)TANF (cash assistance)UnemploymentWICSSI or SSDI

        How would you rate your credit score?

        1 = Very bad2 = Bad3 = About Average4 = Good5 = Very Good6 = Don’t know

        Health and Well-Being

        Select the statement that best reflects your current situation when it comes to affordable medical care or adequate health insurance:

        1 = No medical coverage with immediate need.2 = No medical coverage and great difficulty accessing medical care when needed. Some household members may be in poor health.3 = Some members (e.g. children) have medical coverage.4 = All members can get medical care when needed, but may strain budget.5 = All members are covered by affordable, adequate health insurance.

        Self-efficacy

        Select the statements that best reflects your current situation:

        I will be able to achieve most of the goals that I have set for myself.When facing difficult tasks, I am certain that I will accomplish them.In general, I think I can obtain outcomes that are important to me.I believe I can succeed at most any endeavor to which I set my mind.I will be able to successfully overcome many challenges.I am confident that I can perform effectively on many different tasks.Compared to other people, I can do most tasks very well.Even when things are tough, I can perform quite well.

        Grit

        Select the statements that best reflects your current situation:

        New ideas and projects sometimes distract me from previous ones.Delays and obstacles don’t discourage me.I have been obsessed with a certain idea or project for a short time but later lost interest.I am a hard worker.I often set a goal but later choose to follow a different oneI have difficulty keeping my focus on projects that take more than a few months to complete.I finish whatever I begin.I am hard working and careful.

        Select the statement that best reflects your current situation about physical & mental health:

        1 = My immediate family or I have physical, mental, or substance use concerns that prevent my employment or daily life activities.2 = My immediate family or I have physical, mental, or substance use concerns that often interfere with my employment or daily life activities.3 = My immediate family or I have physical, mental, or substance use concerns that sometimes affect my employment or daily life activities.4 = My immediate family or I have no physical, mental, or substance use concerns that affect my employment or daily life activities.5 = My immediate family and I are healthy and participate in preventive health measures (examples include annual chek-ups, screenings, and vaccinations)

        Work and Life Supports

        Select the statement that best reflects your current situation about food security:

        1 = No food or means to prepare it. Rely to a significant degree on other sources of free or low-cost food.2 = Household is on food stamps.3 = Can meet basic food needs, but requires occasional assistance.4 = Can meet basic food needs without assistance.5 = Can choose to purchase the food that the household desires.

        Please select the statement that best reflects your current situation about housing:

        Homeless or threatened with eviction.In transitional, temporary or substandard housing; and/or current rent/mortgage payment is unaffordable (over 30 percent of income).In stable housing that is safe but only marginally adequate.Household is in safe, adequate subsidized housing.Household is safe, adequate, unsubsidized housing.

        Please select the statement that best reflects your current situation about transportation:

        1 = No access to transportation (public or private), may have car that is inoperable.2 = Transportation is available, but unreliable, unpredictable, unaffordable; may have car but no insurance, license, etc.3 = Transportation is available and reliable, but limited and/or inconvenient; drivers are licensed and minimally insured.4 = Transportation is generally accessible to meet basic travel needs.5 = Transportation is readily available and affordable; car is adequately insured.

        Select the statement that best reflects your current situation about family care (includes child care, senior care and care for people with disabilities):

        1 = Needs dependent care, but none is available or accessible and/or dependent is not eligible.2 = Dependent care is unreliable or unaffordable, inadequate supervision is a problem for what care is available.3 = Affordable subsidized dependent care is available, but limited.4 = Reliable, affordable dependent care is available, no need for subsidies.5 = Able to select quality dependent care of choice

        Select the statement that best reflects your current situation about clothing:

        No clothing or seriously inadequate clothing. (For example, no coat for winter months, shoes with holes in them or soles lacking, not sufficient clothes to assure clean clothes on a daily basis.) Unaware of where to access assistance. Very limited knowledge of resources for low-cost or free options to obtain clothing.Occasionally relies on community clothing banks. Has limited knowledge about community resources and/or financial resources to obtain clothing.Usually has the financial resource to purchase appropriate clothing. Aware of what is appropriate for work environment.Always has a financial resource to purchase appropriate clothing of choice. Aware of what is appropriate for work environment.

        Palmetto Goodwill of SC is requesting additional information from some program participants for use in a pilot project for Goodwill Industries International. This data will be collected and shared, without use of names, for research and analysis. With the understanding that this information will be maintained in a password-protected database accessible only by authorized users, I authorize Goodwill to disclose necessary information, and hold Goodwill free from liability for the exchange of this information.

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