Is It Working? Self Help Guide for Evaluating Vocational and Adult Education Programs: September 1995

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


Appendix A1
Student Intake Form

Name:__________________________________________________________________
         Last                                         First                                            Middle Initial

Address:_______________________________________________________________
                           House                                                     Number Street

_______________________________________________________________________
                    City                                 State                                            Zip Code


 

Telephone(__ __ __)-__ __ __ -__ __ __ __

Date of Application:___/___/___

  1. Birthdate ___/____/____

  2. Sex
    Male ___________________
    Female__________________

  3. Marital status
    Currently married ______________
    Widowed ______________
    Divorced ______________
    Separated ______________
    Never married ______________

  4. Single Parent
    Yes ______________
    No ______________

  5. Race or ethnic group
    American Indian or Alaskan Native______________
    Asian or Pacific Islander ______________
    Black, not of Hispanic origin ______________
    Hispanic ______________
    White, not of Hispanic origin ______________

  6. Number of Years of School Completed
    None ______________
    1 - 4 years ______________
    5 - 8 years ______________
    9 years ______________
    10 years ______________
    11 years ______________
    12 years ______________
    More than 12 years______________

  7. Highest Diploma/Degree Obtained
    None ______________
    GED Certificate ______________
    High School Diploma ______________
    Technical Certificate ______________
    A.A. Degree ______________
    4 year College Graduate ______________
    Other ______________

  8. What is the most important reason you enrolled in this program?
    Required by employer ______________
    Required by another program or agency ______________
    To satisfy family or friends ______________
    To satisfy other personal or employment goals______________

  9. Do you speak a language other than English at home?
    Yes (continue below)______________
    No (skip to 10) ______________

    What language do you speak?
    Spanish ______________
    Asian (Chinese, Vietnamese, Korean, etc.) ______________
    Other ______________

    How well do you read in that language?
    Very well ______________
    Well ______________
    Not well ______________
    Not at all ______________

    How well do you speak English?
    Very well ______________
    Well ______________
    Not well ______________
    Not at all ______________

  10. Are you currently receiving any public assistance or public welfare payments, for example, Supplemental Security Income (SSI), Aid to Families with Dependent Children (AFDC)?
    Yes (skip, to 11) ______________
    No (continue below) ______________

    Did you receive in the last 12 months any public assistance or public welfare payments, for example, Supplemental Security Income (SSI), Aid for Families with Dependent Children (AFDCP)?
    Yes ______________
    No ______________

  11. Did you work full-time or part-time for pay last week?
    No (skip to 12) ______________
    Yes (continue below) ______________

    If employed, where: ____________________________________________

    Describe job: ___________________________________________________

    ______________________________________________________________

    Wages Per Hour: $______________ (Skip to 13)

  12. Were you looking for work during the last four weeks?
    Yes (continue below) ______________
    No (skip to 13) ______________

    Could you have taken a job last week if one had been offered?
    No, already have a job ______________
    No, temporarily ill ______________
    No, other reasons (in school, etc.) ______________
    Yes, could have taken job ______________

  13. How did you learn about this instructional program?
    Family members ______________
    Friend/neighbor ______________
    Work associate/employer ______________
    Newspaper ______________
    Radio ______________
    Television ______________
    Letter, notice or leaflet from school or other community organizations ______________
    Other ______________

  14. Previous Work History:______________________________________________

    ______________________________________________________________________

    ______________________________________________________________________

    ______________________________________________________________________

  15. Vocational Skills:_________________________________________________

    ______________________________________________________________________

    ______________________________________________________________________

    ______________________________________________________________________

    ______________________________________________________________________

  16. Prior Adult Education/Vocational Training:_________________________

    ______________________________________________________________________

    ______________________________________________________________________

    ______________________________________________________________________

    ______________________________________________________________________

  17. Job Interests and Goals:____________________________________________

    ______________________________________________________________________

    ______________________________________________________________________

    ______________________________________________________________________

    ______________________________________________________________________

  18. How important to you are the following reasons for enrolling in this program?
Very
Important		 Somewhat
Important		 Not
Important
a. To improve reading/writing skills ____________ ____________ ____________
b. To improve math skills ____________ ____________ ____________
c. To improve speaking and listening skills ____________ ____________ ____________
d. To get a GED or high school diploma ____________ ____________ ____________
e. To prepare for a vocational or job training program ____________ ____________ ____________
f. To get a job or a better job or qualify for higher pay ____________ ____________ ____________
g. To improve job performance ____________ ____________ ____________
h. To qualify for United States citizenship ____________ ____________ ____________
i. To feel better about myself ____________ ____________ ____________
j. To contribute better to my family and community ____________ ____________ ____________
k. To help my children with schoolwork ____________ ____________ ____________
1. To become less independent on others for help ____________ ____________ ____________
m. To make others feel better about me ____________ ____________ ____________
n. To help continue my education ____________ ____________ ____________

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[Appendix A.] A2. Program Profile