Form 1.5 "Common Intake and Information Form for Adults, Dislocated Workers, Youth, Workforce Center and Partners" - Arkansas

What Is Form 1.5?

This is a legal form that was released by the Arkansas Department of Commerce - Division of Workforce Services - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 10, 2021;
  • The latest edition provided by the Arkansas Department of Commerce - Division of Workforce Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 1.5 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Commerce - Division of Workforce Services.

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Download Form 1.5 "Common Intake and Information Form for Adults, Dislocated Workers, Youth, Workforce Center and Partners" - Arkansas

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Common Intake and Information Form
FORM WIOA I-B – 1.5 (updated 6/10/21)
For Adults, Dislocated Workers, Youth, Workforce Center and Partners
If you are age 18 or older and need help in obtaining employment that will lead to adequate wages so that you
can support yourself and/or your family, we may be able to help you. If you qualify, we offer many career and
training services and assistance that can help you obtain your employment goals. If you are interested in
determining eligibility and services available, we invite you to complete the attached information and return it
to:
You may also call for an appointment at:
If you are 24 years old or younger, you may also qualify for the Youth program. A case manager will help you
determine which program (or both) best fits your educational and employment needs.
You will be asked to document certain information you provide on the application. We can help you obtain
such information, if needed, but your application will be processed more quickly if you could bring the
information with you. We suggest you bring the following documentation if applicable (alternate
documentation can be arranged, if needed):
Drivers’ license, passport, or other government-issued ID that has your picture
Signed Social Security card
U. S. birth certificate, if you have one (If you don’t, there is other documentation we can use.)
If you are not a U. S. Citizen, a permanent resident card or other card stating authority to work in the
United States
If you are a veteran, your DD-214
If you are a disabled veteran, widow or widower of a veteran or an “eligible spouse,” bring VA
documentation of your status if you have it
Selective Service registration card or letter, if applicable (We can obtain the information online, if
needed.)
If you have received a lay-off notice, bring it
If you are attending college, bring a transcript and a degree plan
If you have been accepted into a college program (such as nursing), bring your acceptance letter
Bring documentation of a disability, if you have one and there is documentation
If you are low-income, you may bring documentation, or we will help you obtain it. Low-income
includes receiving cash public assistance (SNAP, TEA, Work Pays, or SSI), and being homeless. If you do
not meet any of these criteria, you may need documentation of the number of people in your
household and the income of all individuals in the home. If you’re not sure what to bring, we can help
you after we talk with you.
Form 1.5
Common Intake and Information Form
Page 1
A proud partner of the American Job Center network
Common Intake and Information Form
FORM WIOA I-B – 1.5 (updated 6/10/21)
For Adults, Dislocated Workers, Youth, Workforce Center and Partners
If you are age 18 or older and need help in obtaining employment that will lead to adequate wages so that you
can support yourself and/or your family, we may be able to help you. If you qualify, we offer many career and
training services and assistance that can help you obtain your employment goals. If you are interested in
determining eligibility and services available, we invite you to complete the attached information and return it
to:
You may also call for an appointment at:
If you are 24 years old or younger, you may also qualify for the Youth program. A case manager will help you
determine which program (or both) best fits your educational and employment needs.
You will be asked to document certain information you provide on the application. We can help you obtain
such information, if needed, but your application will be processed more quickly if you could bring the
information with you. We suggest you bring the following documentation if applicable (alternate
documentation can be arranged, if needed):
Drivers’ license, passport, or other government-issued ID that has your picture
Signed Social Security card
U. S. birth certificate, if you have one (If you don’t, there is other documentation we can use.)
If you are not a U. S. Citizen, a permanent resident card or other card stating authority to work in the
United States
If you are a veteran, your DD-214
If you are a disabled veteran, widow or widower of a veteran or an “eligible spouse,” bring VA
documentation of your status if you have it
Selective Service registration card or letter, if applicable (We can obtain the information online, if
needed.)
If you have received a lay-off notice, bring it
If you are attending college, bring a transcript and a degree plan
If you have been accepted into a college program (such as nursing), bring your acceptance letter
Bring documentation of a disability, if you have one and there is documentation
If you are low-income, you may bring documentation, or we will help you obtain it. Low-income
includes receiving cash public assistance (SNAP, TEA, Work Pays, or SSI), and being homeless. If you do
not meet any of these criteria, you may need documentation of the number of people in your
household and the income of all individuals in the home. If you’re not sure what to bring, we can help
you after we talk with you.
Form 1.5
Common Intake and Information Form
Page 1
A proud partner of the American Job Center network
PERSONAL INFORMATION
Last Name:
First Name:
Middle:
Mailing Address:
City :
Zip:
Physical Address:
City :
Zip:
County:
Telephone
Cell Phone
Do you accept texts? [ ] Yes [ ] No
Message phone:
E-Mail Address:
Relative’s Name:
Tele. #
Another Relative’s Name:
Tele. #
Social Security Number (used for program performance purposes)
Birthdate:
Age:
Sex (at birth): [ ] Male [ ] Female
Are you Hispanic or Latino? [ ] Yes [ ] No [ ] Prefer not to answer
What is your Race? (Select one or more):
[ ] White or Caucasian
[ ] Asian or Asian American
[ ] Black or African American
[ ] Hawaiian or Other Pacific Islander
[ ] American Indian or Alaska Native
[ ] More than one race
[ ] Prefer not to answer
Do you acknowledge a disability that substantially limits one or more major life activity? [ ] Yes [ ] No
If yes, do you need special accommodations for the disability? [ ] Yes [ ] No
If yes, what accommodations do you need?
Do you receive Social Security Disability Insurance? [ ] Yes [ ] No
Do you have trouble solving problems OR reading, writing, and speaking English at a level necessary to function
on the job or at school? [ ] Yes [ ] No
Is English your primary language? [ ] Yes [ ] No
Do you live in a family or community where English is not the primary language spoken? [ ] Yes [ ] No
Are you registered with Selective Service? [ ] Yes [ ] No
Are you a U.S. Citizen? [ ] Yes [ ] No
If no, are you a permanent resident alien? [ ] Yes [ ] No
If no for both above, are you a lawfully admitted refugee, asylees, parolee, or other immigrant
authorized to work in the United States? [ ] Yes [ ] No [ ] N/A
Are you a veteran? [ ] Yes [ ] No
Are you the spouse of a veteran? [ ] Yes [ ] No
Are you a widow or widower of a veteran? [ ] Yes [ ] No
Have you registered with Arkansas Job Link? [ ] Yes [ ] No
[ ] Yes [ ] No
Are you an Arkansas Works referral from the state Medicaid expansion program?
(Arkansas Works is a Governor’s initiative DHS program that refers DHS clients to DWS job service staff for employment assistance)
Form 1.5
Common Intake and Information Form
Page 2
A proud partner of the American Job Center network
Have you been subject to any stage of the youth or adult criminal justice process for committing an offense or
delinquent act, OR do you have trouble obtaining or keeping a job because of an arrest or conviction?
[ ] Yes [ ] No
Are you a single parent (custodial or non-custodial), or a pregnant woman? [ ] Yes [ ] No
Do your customs, beliefs, or practices serve as a hindrance to employment (cultural barrier)? [ ] Yes [ ] No
INCOME
Some of our services have income requirements. We, therefore, need the following information to help
determine need for particular services:
Do you or a family member currently receive (or received in the last 6 months) any of the following (check all that
apply):
[ ] SNAP
[ ] TEA
[ ] Work Pays
[ ] Supplemental Security Income (SSI)
Are you within 2 years of exhausting your lifetime TANF eligibility? [ ] Yes [ ] No
Are you homeless (lack a fixed, regular, and adequate nighttime residence)? [ ] Yes [ ] No
Are you a runaway (under the age of 18 and left home without the permission of your parents/guardians)?
[ ] Yes [ ] No
Are you in foster care, aged out of foster care, or attained the age of 16 and left foster care for kinship
guardianship or adoption or an out-of-home placement? [ ] Yes [ ] No
List all members who live in the household at any time in the last 6 month, their relationship to you, and their
sources of income for the last 6 months:
Family is defined two or more persons related by blood, marriage, or decree of court, who are living in a single residence,
and are included in one or more of the following categories:
A married couple and dependent children
A parent or guardian and dependent children
A married couple
Ask for the definition of a dependent child if needed
Name
Relationship to you
Age
All sources of Income
Self
(If needed, place information about additional household members on back or on additional pages)
Do you certify that the income sources above are all the sources of income for your family?
[ ] Yes [ ] No
If No, Explain:
Form 1.5
Common Intake and Information Form
Page 3
A proud partner of the American Job Center network
EMPLOYMENT INFORMATION
Which best describes your current employment status? (Check all that apply)
[ ] Employed working for wages, self-employed, or working 15+ hours per week unpaid in family
business. “Employed” includes if you are away from job because of vacation, leave, etc.)
[ ] Part-time
[ ] Full-time
(PT is less than 30 hrs/wk or considered PT by your employer)
[ ] Self-employed
[ ] Employed, but received termination notice from employer/military
[ ] Not employed (not working, but available for work and looking for work)
[ ] Exhausted Unemployment Benefits, and don’t have an appropriate job
[ ] Have been unemployed for 27 or more consecutive weeks, but have been looking for work and was
available for work during the entire time
[ ] Not in labor force (not employed and have not actively been looking for work)
Are you a migrant or seasonal farm worker? [ ] Yes [ ] No
Do you currently receive Unemployment Benefits? [ ] Yes [ ] No
Have you received Unemployment Benefits in the past? [ ] Yes [ ] No
If yes, when?
Have you recently been laid off or given notice that you will be laid off? [ ] Yes [ ] No
If so, where?
Layoff date (mm/dd/yyyy):
Did you own a business that recently closed because of a disaster or local economic reasons? [ ] Yes [ ] No
If so, name of business:
Closure date (mm/dd/yyyy):
Why did it close?
Are you a displaced homemaker (a person who has been providing unpaid services to family members in the
home and has been dependent on the income of a family member, but is no longer supported by that income
and is unemployed or underemployed and is experiencing difficulty obtaining or upgrading employment)?
[ ] Yes [ ] No
If yes, give details:
Are you (or were you) the dependent spouse of a member of armed forces on active duty, and the family
income is significantly changed because of a deployment, a call or order to active duty, a permanent change of
state, or the service-connected death or disability of the member? [ ] Yes [ ] No
If yes, give details:
Form 1.5
Common Intake and Information Form
Page 4
A proud partner of the American Job Center network
WORK HISTORY (list current or most recent first. Please list dates as completely as possible.)
Employer Name:
Start:
End:
Address:
City:
State:
Job title:
# Hours per week:
Hourly wage:
Reason for leaving: [ ] Quit [ ] Laid off [ ] Moved from area [ ] Fired [ ] Other:
Employer Name:
Start:
End:
Address:
City:
State:
Job title:
# Hours per week:
Hourly wage:
Reason for leaving: [ ] Quit [ ] Laid off [ ] Moved from area [ ] Fired [ ] Other:
Employer Name:
Start:
End:
Address:
City:
State:
Job title:
# Hours per week:
Hourly wage:
Reason for leaving: [ ] Quit [ ] Laid off [ ] Moved from area [ ] Fired [ ] Other:
Employer Name:
Start:
End:
Address:
City:
State:
Job title:
# Hours per week:
Hourly wage:
Reason for leaving: [ ] Quit [ ] Laid off [ ] Moved from area [ ] Fired [ ] Other:
EDUCATION
Do you have a high school diploma or GED®? [ ] Yes [ ] No
If yes, from where?
If no, what is the highest grade you completed?
Do you have a college degree or certificate? [ ] Yes [ ] No
If yes, what is your highest degree or certificate?
What was your major?
Do you currently attend secondary school (high school or junior high)? [ ] Yes [ ] No
If so, where?
What grade are you in?
Are you working toward a GED®? [ ] Yes [ ] No
Are you currently enrolled in postsecondary education (college, technical school, etc.)? [ ] Yes [ ] No
If yes, where?
What is your major?
When do you expect to finish?
Do you have college work toward an unfinished certificate or degree? [ ] Yes [ ] No
If so, where?
Why did you stop?
Form 1.5
Common Intake and Information Form
Page 5
A proud partner of the American Job Center network
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