Form DEO-SNAP E&T0011 "Employment and Training (E&t) Interest and Skills Questionnaire - Supplemental Nutrition Assistance Program (Snap)" - Florida

What Is Form DEO-SNAP E&T0011?

This is a legal form that was released by the Florida Department of Economic Opportunity - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2012;
  • The latest edition provided by the Florida Department of Economic Opportunity;
  • 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 DEO-SNAP E&T0011 by clicking the link below or browse more documents and templates provided by the Florida Department of Economic Opportunity.

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Supplemental Nutrition Assistance Program (SNAP)
Employment and Training (E&T)
Interest and Skills Questionnaire
This questionnaire is a tool used by the Supplemental Nutrition Assistance Program (SNAP) Employment and
Training (E&T). The SNAP E&T program staff will use the information you provide to help you develop a
career path. The SNAP E&T program staff will also use this information to help you pick an activity to assist
you in building the skills you need to help you move forward on your career path. Please print the information
requested below.
Name:
Case Number:
Telephone Number:
Email Address:
Address:
City/State/Zip:
Mailing Address (if different):
City/State/Zip:
1. Please list the highest grade you completed below. If you received a diploma or degree, please list the
degree, the school you attended and the year you completed your degree.
2. Do you have a professional or technical certificate or license that is current?  Yes
 No
If yes, please list all professional and technical certificates or licenses and the year you received your
certification. (Examples include: CDL license, Certified Nursing Assistant – CNA, Certificate in Microsoft
Office, etc.)
3. Are you attending school now?  Yes  No
A. If yes, where are you going to school, what are you going to school for and how many hours of
classes are you taking?
B. If no, would you like to go back to school?  Yes  No (if no, skip to question 4)
C. What would you like to go to school for?
D. What would make you drop out of school?
4. Have you applied for or ever received financial assistance?  Yes  No
5. Have you ever been enrolled in special education classes? Yes No
6. Have you ever been tested for a learning disability? Yes No
7. Do you have trouble working with numbers in columns? Yes No
8. Do you have trouble remembering how to spell simple words? Yes No
DEO-SNAP E&T 0011, October 2012
AWI-FSET 0011, Revised 04/2011
Page 1 of 4
(Replaces
Supplemental Nutrition Assistance Program (SNAP)
Employment and Training (E&T)
Interest and Skills Questionnaire
This questionnaire is a tool used by the Supplemental Nutrition Assistance Program (SNAP) Employment and
Training (E&T). The SNAP E&T program staff will use the information you provide to help you develop a
career path. The SNAP E&T program staff will also use this information to help you pick an activity to assist
you in building the skills you need to help you move forward on your career path. Please print the information
requested below.
Name:
Case Number:
Telephone Number:
Email Address:
Address:
City/State/Zip:
Mailing Address (if different):
City/State/Zip:
1. Please list the highest grade you completed below. If you received a diploma or degree, please list the
degree, the school you attended and the year you completed your degree.
2. Do you have a professional or technical certificate or license that is current?  Yes
 No
If yes, please list all professional and technical certificates or licenses and the year you received your
certification. (Examples include: CDL license, Certified Nursing Assistant – CNA, Certificate in Microsoft
Office, etc.)
3. Are you attending school now?  Yes  No
A. If yes, where are you going to school, what are you going to school for and how many hours of
classes are you taking?
B. If no, would you like to go back to school?  Yes  No (if no, skip to question 4)
C. What would you like to go to school for?
D. What would make you drop out of school?
4. Have you applied for or ever received financial assistance?  Yes  No
5. Have you ever been enrolled in special education classes? Yes No
6. Have you ever been tested for a learning disability? Yes No
7. Do you have trouble working with numbers in columns? Yes No
8. Do you have trouble remembering how to spell simple words? Yes No
DEO-SNAP E&T 0011, October 2012
AWI-FSET 0011, Revised 04/2011
Page 1 of 4
(Replaces
9. Do you have trouble filling out forms? Yes No
10. Do you have trouble adding and subtracting small numbers in your head? Yes No
11. What language(s) do you speak?
12. Are you a Veteran? Yes No
A. If yes, what skills did you receive in your military training?
B. Are you the spouse or dependent of a military veteran? Yes No
13. Are you volunteering with a for-profit or not-for-profit employer in your community? Yes
No If no,
would you like to volunteer in your community? Yes
No
14. What type of work would you like to do?
15. Are you currently looking for a job? Yes No
16. What type of job would you like to get in the next six months with your current skills?
17. Are you having difficulties finding work? Yes No
18. What do you think keeps you from getting or finding a job?
19. Are you re-entering the workforce after being a homemaker? Yes No
20. Did you lose your job because your skills were no longer in demand, your job went overseas, the business
closed, or there was a layoff? Yes No
A. If yes, describe the work you were doing?
B. What city were you working in?
C. What was the business name/employer?
21. Please check all of your skills and abilities:
I type fast
I can use the computer
I can drive a truck or a
I have worked in a
I can answer multiple phone
bus
warehouse
lines
I have worked in
I can file
I can use a cash register
I have worked in a
I have customer service
an office
restaurant cooking
skills
I have worked in
I have worked with kids
I have worked in a
I have worked in a hotel.
Other: _______________
construction
medical office
DEO-SNAP E&T 0011, October 2012
AWI-FSET 0011, Revised 04/2011
Page 2 of 4
(Replaces
Work History Summary (List Most Recent Employer First)
1. Name of Employer
Job Title
Full-time
Part-time
Start Date
End Date
Ending Salary _______ Hourly
Weekly  Other
Beginning Salary
What tasks did you perform at this job?
What did you like the most about this job?
What did you like the least?
Reason for leaving
2. Name of Employer
Job Title
Full-time
Part-time
Start Date
End Date
Hourly
Weekly  Other
Beginning Salary
Ending Salary _______
What tasks did you perform at this job?
What tasks did you like the most?
What tasks did you like the least?
Reason for leaving
3. If you are working, did you report your employment to the Department of Children and Families? Yes
No
Personal Summary
1. Do you have any medical, mental health or physical limitations that limit you in your work activity or
training? Yes
No
If yes, explain:
2. Have any of the following issues ever caused a problem with you finding employment, keeping a job or
keeping you from going to school?
A.
B.
C.
D.
E.
Drugs
Domestic Violence
Depression
Alcohol
Other:
You can receive confidential services at any time. If you are a victim of domestic violence, you can disclose that you
are dealing with domestic violence at any time. If you do not feel safe, there is a confidential hotline you can call as
well. The number is 1-800-500-1119.
3. Are you currently involved in a treatment center or program (please describe)?
4. Do you have a criminal record and/or criminal conviction? Yes
No
DEO-SNAP E&T 0011, October 2012
AWI-FSET 0011, Revised 04/2011
Page 3 of 4
(Replaces
5. Did you go to jail? Yes
No
6. Are you on probation or parole? Yes
No
A. If yes, what are the terms of your release?
7. Are you currently going through a legal issue? Yes
No
Bus
Personal Vehicle
Walk
Bike
8. How do you plan to get to work or training activities?
 Other
9. Do you need help paying for transportation? Yes
No
10. Do you have a valid driver’s license? Yes
No
11. Do you have a place to live? Yes
No
If no, do you need assistance in finding a place to live?
Yes
No If yes, please explain:
12. Have you applied for Unemployment Compensation? Yes
No If yes, when?
13. Are you pregnant or a parent (and your children live with you)? Yes
No
14. Are you a foster child or in the foster care system? Yes
No
______________________________________
__________________________________________
Volunteer’s Signature
Program Staff’s Signature
______________________________________
__________________________________________
Date
Date
Comments: (OFFICIAL USE ONLY)
DEO-SNAP E&T 0011, October 2012
AWI-FSET 0011, Revised 04/2011
Page 4 of 4
(Replaces