ROSS Program: Resident Opportunities & Self-Sufficiency Assessment

Personal Information:

Move In Date:

Resident ID#:

Name:

Street Address:

City:

State:

Zip Code:

Home Phone Number:

Work Phone Number:

Cell Phone Number:

Email Address:

Confirm Email Address:

Date of Birth:

Age:

Driver's License/Identification # State:

Driver's License/Identification #:

Gender:

Male

Female

US Citizen:

Yes

No

Immigrant:

Yes

No

Partnership Status:

Single

Married

Domestic Partnership

Separated

Divorced

Widowed

Other

What is your Race (Please check all that apply):

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other

Income Source (Please check all that apply):

Employment

TANF

Unemployment

Child Support

SSI

Retirement

VA Benefits

Spousal Support

Workman's Comp.

No Income

SSDI

SNAP

Other

Social Security $ per Month:

SSDI $ per Month:

Retirement $ per Month:

SSI $ per Month:

Veterans $ per Month:

SNAP $ per Month:

Do you have transportation?

Yes

No

Have you ever been convicted of a felony?

Yes

No

If you have been convicted of a felony, explain when:

Are you currently on parole/probation?

Yes

No

Are you a Veteran?

Yes

No

Did you receive an honorable discharge?

Yes

No

Emergency Contact Information

Emergency Contact's Name:

Emergency Contact's Address:

Emergency Contact's City:

Emergency Contact's State:

Emergency Contact's Zip:

Emergency Contact's Primary Telephone:

Emergency Contact's Secondary Telephone:

Emergency Contact's Email:

Confirm Emergency Contact's Email:

Emergency Contact's Relationship:

Contact:

Often

Rarely

Phone

Hospital Preference in Case of Emergency:

Family Information:

Living With:

Self Only

Spouse

Domestic Partner

Separated

Child(ren)/Grandchild(ren)

Care Provider

Other

How many children do you have?

Ages of Children (separate with commas):

How many school-aged children do you have?

Did you receive an Earned Income Tax Credit for the most recent tax year?

Yes

No

Are you in need of childcare due to employment, school, or on the job training program?

Yes

No

Do you need assistance with enrolling any children in school?

Yes

No

Do your children have health and dental insurance?

Yes

No

Do your children have up to date medical and dental examinations?

Yes

No

Appointment dates:

Education Information:

Do you have a high school diploma or GED?

Yes - H.S. Diploma

Yes - GED

No

Are you able to read and write in English?

Yes

No

If you do not have your high school diploma or GED, please indicate the highest grade you completed:

1

2

3

4

5

6

7

8

9

10

11

12

Do you have any college hours?

Yes

No

If you do have any college hours, how many and what was your major? (List a college degree if applicable):

Employment History

Are you currently employed? (If yes - complete the following information):

Yes

No

Start date of current employment:

Full or Part-time:

Full-Time

Part-time

Hours work per week:

Rate of pay:

Earnings before Taxes/Deductions:

What is your Job Title/Profession?

If you are not currently employed, what are the most severe problems or barriers that prevent you from getting a job:

Lack of Job Skills/Education

Domestic Abuse in Family

Health Problems

Drug/Alcohol Use

Lack of Transportation

Lack of Child Care

Language Barriers

Family Problems

Lack of Resume Writing or Job-Hunting Skills

Lack of Professional Attire

Lack of Emotional Support

Other

Please describe your ideal job. Include things such as: ideal pay rate, hours, benefits, environment, and job duties.

Medical:

Do you have a disability determined by a physician, Medicaid, or other authority?

Yes

No

If yes, what is your primary physical impairment?

If yes, what is your primary mental impairment?

Do you have Health insurance?

Yes

No

If yes, please provide the insurance organization.

Did you receive a routine medical examination by a health care provider in the prior 12 months?

Yes

No

Medicare:

Yes

No

Medicaid:

Yes

No

Medicare #:

Medicaid #:

Primary Healthcare Provider:

Primary Healthcare Phone:

Primary Healthcare Email:

Primary Healthcare Address:

Dentist:

Dentist Phone:

Dentist Email:

Dentist Address:

Pharmacy:

Pharmacy Phone:

Pharmacy Email:

Pharmacy Address:

Mental Health:

Are you currently or have you in the past received therapeutic services?

Yes

No

If so, where?

Do you have periods of feeling sad or downhearted?

If so, how often?

Do you feel safe in your home?

Life Planning:

Living Will:

Yes and I have a copy

Yes, but I do not have a copy

No I do not have a living will

Power of Attorney:

Yes

No

Durable Power of Attorney (for healthcare):

Yes

No

Life Insurance:

Yes

No

Funeral Arrangements:

Yes

No

Support Services:

Please check the services that you would like to receive.

Assistance with Daily Living

Meals Services to meet Nutritional Needs

Personal Emergency Response Resources

Disability Service Counseling

Community Safety

Wellness Programs

Resident Organization Empowerment

Civic Engagement Resources and Training

Parenting Courses

Financial Literacy

Soft Skills Training

Basic Education

Job Training, Search, Placement Assistance

Home Ownership

Supportive Services

Mentor

Other

Have you been affected by COVID-19 (childcare, employment)?

Yes

No

The Resident Opportunities and Self-Sufficiency (ROSS) program is a volunteer program. Are you willing to maintain regular contact with the ROSS Service Coordinator?

Yes

No

Participant Signature:*

Signature Date:*