JobTrain Career Center Intake Form

Consent and Information Release

JobTrain’s Salesforce System

During the registration process and throughout your participation in the JobTrain program, JobTrain will collect certain personal information from you. This information is necessary for us to run our programs, receive funding, improve our services, and better understand your needs.

We will only collect information that is necessary to achieve these goals and will never share it outside of the JobTrain family of programs without your consent. To protect your rights and privacy, JobTrain uses a secure electronic database system called Salesforce to store any personal information that is collected throughout the course of your participation in our JobTrain Program. The collection and use of all personal information by JobTrain is guided by strict standards of confidentiality.

The information gathered in Salesforce is used by internal staff to maximize service delivery to our clients. Additionally, the information gathered in Salesforce is shared with JobTrain’s internal Impact department to evaluate and improve service delivery. Data shared with required funders is deidentified and sent aggregated without individualized information unless otherwise notified in advance.

RELEASE STATEMENT

I acknowledge that I received and reviewed the Salesforce Consent and Information Release Form and that I understand and agree to its terms and conditions, including JobTrain’s collection, storage, and dissemination of my personal information within the JobTrain family via the Salesforce database.

(Client) Last Name

(Client) First Name

Middle Initial

Birthday (MM/DD/YYYY)

Do you consent?

I consentI decline

End of Intake

Because you disagree with our data collection through Salesforce, we will end the digital intake form here. Please work with your Employment Specialist to complete the intake form on paper.

Client Information

Which JobTrain Career Center are you working with

Please select the employment specialist you are working with

First Name

Preferred Name

Middle Name

Last Name

Suffix

Date of Birth

Mobile Phone

Email (If you have provided us an email address, please put in the same address to help us locate you in our system.)

Street Address

City

County

Please specify City

State/Province

Postal Code

Gender Identity

Preferred pronoun

Please specify Preferred Pronoun

Ethnicity

Highest Education Level Completed

Please specify Ethnicity

Please specify Foreign Degree

Preferred Language

How did you hear about us?

Please specify preferred language

Please specify where you heard about us.

Employment Status Information

Do you have authorization to work?

What is your current employment status?

What is the last day you were employed? (If you are currently employed, please fill in today's date. If you don't remember the exact date you were last employed, use the first day of the month or year)

What is your most recent or current hourly wage (If you are/were on monthly or annual salary, please convert it to average hourly wage. If you do not remember or prefer not to answer, please write so.)

What is your most recent or current job title? (If you do not remember or prefer not to answer, please write so.)

What is your most recent or current employer's name? (If you do not remember or prefer not to answer, please write so.)

Barrier to Employment Information

Next, we will be asking if the following descriptions fit you. We ask these questions because these are common challenges to finding or keeping a job. Providing the information will not affect our service to you in any way, but will help us better assist you and understand our client population.

	Yes	No	Prefer not to answer
Do you feel that your English skills limit your ability to find or keep a job?
Do you lack reliable means of transportation?
Are you homeless or at risk of being homeless (meaning not having a fixed, regular, and adequate nighttime residence that is not a shelter)?
Have you been convicted or incarcerated?
Are you a military veteran?
Do you use any substances (including alcohol, illicit drugs, or prescription medication not as prescribed) in a way that negatively affected your work performance?
Do you have a documented disability that may influence your ability to work? The disability should be recognized by a medical professional or government agency.
Do you currently receive food stamps?
Do you currently receive any other kinds of public assistance?
Do you have significant reading or writing challenges that affect your ability to work?
Do you find it challenging completing daily digital tasks on your own (including but not limiting to setting up and using email, the folder function in Windows/MacOS, using web browser, Zoom, keyboard, and mouse)?

Do you want to share with us any other conditions that may bring challenges to employment?

Full-time	Part-time
Short-term Work/Day labor	Other

Morning	Afternoon
Evening	Overnight
Not applicable to me

Education	Health/Healthcare
Labor/Trade/Union	Office/Admin
Operations/Logistics	Restaurant/Hospitality
Sales/Business	Social/Nonprofit
Other