Ohio Department of Job and Family Services

Ohio Rapid Response Event Data

Ohio Workforce Case Management System

Mini-Registration

JFS8124BT T

JFS08124 (Rev. 10/2013) Page 1 of 3

Address:

State: Zip Code:

Gender:

We’re interested in helping you return to work as quickly as possible. Please complete the information requested below about you. This provides us with basic information to begin the registration process for the Ohio Workforce Case Management System. Further information may be required from you to determine eligibility for additional services.

Company Name:

Email Address:

First Name MI Last Name

City:

Contact Phone:

Date of Birth:

Month Day Year

Last day worked:

Month Day Year

[ O Male O Female ]

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*JFS8124C*

Please fill in the appropriate circles and print clearly

Highest Grade in School Completed (Choose one below):

O Did Not Complete High School O Some College, No Degree O Bachelor’s Degree

O High School Diploma /GED O Associate Degree/Technical Degree O Graduate Degree

Education Information

Current Trade / Vocational Training or Skills (Choose one below): O No Trade/Vocational Training O Some Trade/Technical Training, No Certificate

O Trade/Vocational Certificate or Licensure (Please provide information below): Please Specify:

O Any additional training (Please provide information below):

Demographic Information

O Yes O No Is your spouse a veteran?

[ O 18 - 21 O 22 - 35 O 36 - 49 O 50 - 64 O 65+ ]

Please indicate your gender and age range:

In which county do you live?

Are you an Armed Forces veteran?

[ O Male O Female ]

O Yes [ O No O Not married ] O Surviving spouse

If yes, is your spouse currently serving in the Armed Forces? O Yes O No

Zip Code:

Ohio Department of Job and Family Services

Ohio Rapid Response Workforce Survey Information from this survey is strictly confidential. Results will be analyzed for re-employment, retraining assistance, and research purposes only.

JFS08124 (Rev. 10/2013) Page 2 of 3

Employment Information

Last day of work:

Current or most recent job title:

If date last worked is not known, please select a range below:

O within 30 days O within 90 days O within 180 days

O within 60 days O within 120 days O more than 180 days

O unknown

Company:

Month Day Year

Average number of hours worked per week? How many full years of service do you have with this company? O Less than 20 hours O 36- 40 hours O Less than 1 year O 10-14 years O 25-29 years O 20-29 hours O More than 40 hours O 1-4 years O 15-19 years O 30 or more yearsO 30-35 hours O 5-9 years O 20-24 years

O Under $9.25 / Under $19,240 O $14.50-$18.24 / $30,160-$37,959 O $28.75-$35.99 / $59,800-$74,879 O $9.25-$11.49 / $19,240-$23,919 O $18.25-$22.74 / $37,960-$47,319 O $36.00-$45.24 / $74,880-$94,119 O $11.50-$14.49 / $23,920-$30,159 O $22.75-28.74 / $47,320-$59,799 O $45.25 and over / $94,120 and over

Please indicate your pay range for this job:

Please select the job family which best fits your desired job type: (Please select all that apply) O Architecture & Engineering O Farming, Fishing, & Forestry O Office & Administrative SupportO Arts, Design, Entertainment, Sports, & Media O Food Preparation & Serving Related O Personal Care & ServicesO Building & Grounds Cleaning & Maintenance O Healthcare Practitioner & Technical O Physical & Social SciencesO Business & Financial Operations O Healthcare Support O ProductionO Community & Social Services O Installation, Maintenance, & Repair O Protective ServicesO Computer & Mathematics O Legal O Sales & RelatedO Construction & Extraction O Management O Transportation & Materials Moving O Education, Training, and LibraryO O Would you be willing to relocate for an employment opportunity? Relocate within the state: O Yes O No Relocate nationwide: O Yes O No

What do you want to do next?

Please indicate the things you are able to do on a computer:

O Access the Internet O Write letters or other documents O Send & receive e-mail O Do financial record keeping or bookwork

Would you be interested in attending workshops on the following topics? (Choose all that apply)

O Job Search & Social Media O Resume O Interviewing O Career Exploration

Have you worked in other occupations in the last five years? O Yes O NoPlease specify:

1)

2)

3)

O Job search assistance O Budgeting & paying my bills without a jobO Understanding how my skills & experience relate to new jobs O Helping my family through this current situationO Developing a resume O Deciding which school would be best for meO Interviewing skills O Tuition & booksO Learning how to find a new job O Paying for child care while going to schoolO Filling out job applications O Transportation expenses to & from schoolO Dealing with my loss of employment O Paying moving expensesO Other, Please Specify

Would you like assistance with any of the following? (Choose all that apply)

What training or education would you be interested in? (Choose all that apply)

O Reading skills training O Basic computer skills trainingO Writing skills training O Finishing/Obtaining a Trade/Vocational Certificate or Licensure O Finishing/Obtaining a GED/High School Equivalency O Finishing/Obtaining an Undergraduate DegreeO Finishing/Obtaining an Associate Degree O Finishing/Obtaining a Graduate DegreeO Other, Please Specify

Where do you look to find employment opportunities? (Choose all that apply) O Ohiomeansjobs.comO NewspapersO Social Media (For example: Facebook; Twitter; LinkedIn)O Other, Please Specify:

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What is the preferred maximum number of miles you are willing to commute one way for employment?

O 10 or less O20 O30 O40 O 50 or more

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O Seek employment immediately O Already have a job lined up O Start my own businessO Attend school/training O Retirement/leaving the workforce O Obtain additional certificationO Undecided O Other, Please Specify

Job Search Assistance and Other Information