A r c h i v e d I n f o r m a t i o n

Choosing Life Skills - January 1998

Appendix I: Life Skills Needs Assessment Form

I. Facility Data

Name of Facility	___________________________________
Type of Facility	___________________________________
Total Current Population	___________________________________
Number of Clients Expected to Go Back to Community Coming Year	___________________________________
Average Length of Stay at Facility (in months)	___________________________________
Number Expected to Be Available for Life Skills Next Year	___________________________________

II. Characteristics of Expected Life Skills Students

Gender

Male:
Number _________ % of Total __________

Female:
Number _________ % of Total __________

Age

Range from ______ to ______ years; Median ______ years

Ethnicity

African American:
Number ____________ % of Total __________

Asian:
Number ____________ % of Total __________

Caucasian:
Number ____________ % of Total __________

Hispanic:
Number ____________ % of Total __________

Native American:
Number ____________ % of Total __________

Other (explain):
Number ____________ % of Total __________

__________________________________________________________________

III. Client Educational Level

Reading Level

(Test used to determine reading level ___________________________)

Below 6th Grade:
Number ____________ % of Total __________

Grade 6-9:
Number ____________ % of Total __________

10 and above:
Number ____________ % of Total __________

GED/High School Diploma

H.S. diploma:
Number ____________ % of Total __________

GED certificate:
Number ____________ % of Total __________

Neither:
Number ____________ % of Total __________

Special Populations

Special Education:
Number ____________ % of Total __________

ESL:
Number ____________ % of Total __________

Other (describe):
Number ____________ % of Total __________

___________________________________________________________________

IV. Client Employment Data

Client's Employment Prior to Arrest or Entering Facility

No Work History:
Number ____________ % of Total __________

Unemployed:
Number ____________ % of Total __________

Part Time Only:
Number ____________ % of Total __________

Temporary Labor:
Number ____________ % of Total __________

Unskilled Full-time:
Number ____________ % of Total __________

Skilled Full-time:
Number ____________ % of Total __________

V. Prioritized Areas of Need Reported by Facility Staff

Client's Employment Prior to Arrest or Entering Facility

Priority 1 ________________________________________________________

Priority 2 ________________________________________________________

Priority 3 ________________________________________________________

Priority 4 ________________________________________________________

Priority 5 ________________________________________________________

Additional Comments:

______________________________________________________________

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[The Janus Employability Skills Program]

[Appendix II: Life Skills Product Data Form]