CWTP Intake Form - Pilipino Workers Center of Southern California

Pilipino Workers Center of Southern California

1 General Info
2 General Questionaire
3 Current Job Info
4 Job Experience

General Info

Full Name

Phone Number

Current Address

Zip Code

Did you mean?

Date of Birth

Gender

Race

Ethnicity

General Questionaire

Are you familiar with worker cooperatives?

Are you comfortable with using technology, such as a laptop, tablet, and smartphone?

Yes No

Do you have access to technology & internet at home?

No access to technology or the internet Has technology but limited access to the internet Has some access to technology and the internet Has access to technology and the internet

What is your current living situation?

Currently homeless Facing eviction Residing in temporary housing Has stable housing for at least 6 months Secure housing

Do you have enough income to cover basic needs?

No income Income inadequate for meeting basic needs Income sufficient and stable for meeting basic needs

Are you currently able to access food?

Completely relies on free food Majority of food needs purchased with food assistance (CalFresh) Occasionally depends on supplemental food programs Can meet basic food needs Always able to purchase food

Do you have access to transportation when you need it?

No access to transportation Transportation is available but unreliable/ unaffordable Has transportation needs met some of the time Has transportation needs met most of the time Transportation is available and affordable.

Do you have access and the means to receive health care?

No medical coverage, current need for medical/dental/vision care Has medical coverage, difficulty keeping routine medical/dental/vision care appointments Has medical coverage and can access care when needed

Do you currently have issues with substance abuse?

Severe alcohol use and/or chemical dependence Significant use of substances Occasional use of substances No alcohol/drug use

Do you have dependent care needs?

Needs dependent care Dependent care is unreliable/unaffordable and/or inadequate Affordable or subsidized dependent care is available Able to select quality dependent care of choice

Has anyone in your household ever received public assistance (Temporary Assistance for Needy Families, Medicaid, Food Stamps, General Assistance/General Relief, etc.)?

Yes No

Do you have skills/education/training needed for job opportunities?

Minimal to no skills/education/training Limited skills/education/training Some skills/education/training Sufficient skills/education/training Strong skills/education/training

Is English your second language?

Yes No

Do you feel that you would benefit from improving your English skills?

Yes No

Do you have the ability to commit to the entire schedule of training?

Yes No

Are there any other needs or circumstances we should be aware of?

Current Job Info

Are you currently working?

Yes No

Industry

Hourly Wage

Yearly Income

Do you experience barriers to employment either due to your immigration status or limited English proficiency?

Yes No

Have you experienced a decrease in income or reduced work hours due to the Covid-19 pandemic?

Yes No

Have you ever contracted Covid-19?

Yes No

Have you experienced personal loss or any other negative impact from Covid-19?

Job Experience

Have you ever cared for someone before?

Yes No

If so, how long?

What kind of care have you given? (Check all that apply) Helped someone with memory loss (like Alzheimer's or Dementia) Helped someone move or get up (lifting or transferring) Helped someone near the end of their life (Hospice Care) Used Medical Tools or machines (like oxygen, wheelchairs, etc.)

Did you finish the Track 1 Caregiver Training with us?

Yes No

Are you comfortable learning new caregiving skills?

Yes No Not Sure

Are you comfortable learning new caregiving skills?

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