Family Self Sufficiency Program – Participant Assessment

Contact Information

First Name *

Last Name *

Street *

Apt

City *

State *

Zip Code *

Email *

Cell Phone

Home Phone

What is your preferred contact method? * EmailSend a text messageCall my cell phoneCall my home phone

Household Information

Are you the head of the Household? * YesNo

Housing Authority Program * Public HousingMRVP Participant

What is the FULL name of the Head of Household? *

What is your relationship to the Head of Household? * ChildSpouse / PartnerParentOther Adult

Is anyone else in your household participating in the SSP program? * YesNo

Do you currently have a checking account? * YesNo

Do you currently have a savings account? * YesNo

Demographic Information

Date of Birth (MM/DD/YYYY) *

Gender * FemaleMaleOther

Please select your race * Black or African AmericanAsianWhiteAmerican Indian/Alaskan NativeNative Hawaiian/Other Pacific IslanderMore than one racePrefer not to say

Are you Hispanic or Latino/a? * YesNo

What is the primary language you speak at home? *

Do you feel comfortable having a conversation in English? * YesNo

Education

What is the highest level of education that you have completed? * Some high school or lessHigh school diploma/GED/HISETVocational or professional degree or certificateSome collegeAssociate's degreeBachelor's degreeMasters or Doctoral degree

Where did you complete your highest level of education? * In the United States (including Puerto Rico and other U.S. Territories)In another country

Are you currently a student? * NoYes, I am a full-time studentYes, I am a part-time student

Current Education Program

In which type of educational program are you enrolled? *

What is the area you are studying? *

Name of the school / agency

Start date of studies

Employment

What is your employment status? * Working one full time job (35+ hours per week)Working one part-time job (10-34 hours per week)Working more than one jobI am currently not working

Employment Details

How much do you currently earn from your job(s), before taxes?

$ per HourWeekMonthYear

How many hours do you currently work in a typical week?

Employer's Name (s)

Employment Industry

Job title (s)

Participant's job benefits. (press and hold Ctrl to select more than one)

Is the participant's job....? * Goal JobBridge Job

Is participant's job a career ladder job? * YesNo

Subsidies

Does your family currently use any of the following?

	Yes	No	Don't Know
SNAP (also known as "food stamps") *	YesNoDon't Know
MassHealth/Health Connector *	YesNoDon't Know
WIC Assistance (Women, Infants and Children) *	YesNoDon't Know
TANF (Welfare) *	YesNoDon't Know
SS/SSI *	YesNoDon't Know
Unemployment *	YesNoDon't Know

Does your family have access to the child care that meets your needs? * YesNoNot Applicable

Are you receiving any additional subsidies? (Please list)

Goals and Interests

What support services would you be interested in receiving (Press and hold the Ctrl button to choose more than one option)?

What are you looking to achieve? (Press and hold the Ctrl button to choose more than one option)?

Family Self Sufficiency Program – Participant Assessment