Resident Opportunities & Self-Sufficiency Assessment
For current residents of Poplar Bluff Housing Authority
Personal & Family Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
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Gender
*
Male
Female
Age
*
Do you have your own transportation?
*
Yes
No
Income Sources - Check all that apply
*
Employment
Retirement
TANF
VA Benefits
Unemployment
Spousal Support
Child Support
Workman's Comp
SSI
No Income
Number of Children
Ages of children
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Education Information
Highest Level of Education
*
Bachelors Degree
Associate's Degree
Some College
Highschool Diploma
GED
Other
Highest Grade Completed
*
1 - 12
College Major
*
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Employment History
Currently Employed
*
Yes
No
Start Date of Current Employment
*
-
Month
-
Day
Year
Date
Hours per week
*
Pay Rate
*
Ex: 15/hr or 35k/year
Are You Disabled?
*
Yes
Yes, and receiving benefits
No
What are the most serious problems or barriers that prevent you from getting a job?
*
Lack of job skills/education
Lack of transportation
Lack of resume writing or job hunting skills
Lack of emotional support
Domestic abuse in family
Lack of child care
Health problems
Language barriers
Drug/Alcohol Use
Family problems
Lack of professional attire
Other
Describe your ideal job. Include things such as pay rate, hours, benefits, work environment and duties
*
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
Signature
*
Clear
Submit
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