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VIRGINIA DEPARTMENT OF SOCIAL SERVICES SNAP E&T Assessment Form

10/24 VOLUME V, PART XXV, APPENDIX II, PAGE 12

SNAP E&T ASSESSMENT FORM

FORM NUMBER - 032-22-1090

PURPOSE OF FORM - This form is initially completed by the Employment Services Program (ESP) participant and worker at the time of the assessment interview. The form records information concerning the ESP participant's educational background, employment history, interests, employment goals and employment barriers.

USE OF FORM - The information on this form is used to assess the job readiness of the participant and serves as a foundation for development of the participant's Activity and Service Plan (032-02- 302). Date information added after the initial assessment to show MM/DD/YY of entry.

NUMBER OF COPIES – One (provide participant with a copy of pages 1- 6).

DISPOSITION OF COPIES - Original will be maintained in the participant’s case record.

INSTRUCTIONS FOR PREPARATION OF FORM - Identifying Information/Date/Type of Assessment/Category - Date is MM/DD/YY the assessment or reassessment is conducted. Check the appropriate block to indicate ''Assessment'' for initial assessment or ''Reassessment'' for reassessment interviews.

On page 1, the program participant will provide their name, case number, contact information, primary language, and the date that they started the assessment form. The instruction directs the program participant to answer as many questions as possible.

The section “Consideration in Employment Planning” is on the first page and designed to allow the program participant and worker to identify issues which may impact the client’s progress toward self- sufficiency and economic stability. If problems are identified, the program participant has an opportunity to decide how these issues will be resolved. This section is in the beginning of the assessment to address possible barriers in the early stages of the assessment.

The following sections are designed to allow the participant to identify issues related to childcare, transportation, housing, and the participant’s health, which may impact the client’s progress toward self-sufficiency and economic stability.

A. CHILDCARE B. TRANSPORTATION C. HOUSING SITUATION D. HEALTH (Note: This section does not replace completion of “Do You Have a Disability” Form.)

The following sections are designed to capture the program participant’s employment goals, interests, and prior experience. This information is very useful in the career planning process as the worker helps the participant to self-identify their strengths, career preferences and employment/training/educational paths.

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