CNA STaT Customized Training Funding Eligibility Pre-Screening

PLEASE READ AND FOLLOW ALL INSTRUCTIONS FOR THE BEST CHANCE TO BE SELECTED FOR THE ST. TAMMANY PARISH HOSPITAL CNA TRAINING PROGRAM.

We are seeking to fill 20 slots for this exciting opportunity. This is a 5 week training program to become a Certified Nursing Assistant with STPH that will be starting November 15th and classes will be held at Northshore Technical College in Lacombe.

YOU MUST be at least 18 yrs old or older, have a high school diploma or equivalent, clean background, and drug-free. You must also have a positive attitude, a desire to help, and be part of a team. You must also either live or want to work in St. Tammany Parish.

Tri-Parish Works and St. Tammany Parish Hospital will be investing more than $100,000 to make this program available at no cost to the students and provide additional stipends. Tuition funding is made possible through the Workforce Innovation Opportunity Act and requires applicants to meet eligibility. The information you provide is separate from your application with St. Tammany Parish Hospital.

Please complete all questions with accurate information so that we may assess your situation and provide the most assistance. If you are likely to be eligible based on your answers, you will be contacted to provide additional documentation to verify your eligibility.

If you have any questions about the pre-screener, please email lcarrone@triparishworks.net

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* 1. Please provide the following contact information

First Name *

Last Name *

Last 4 digits of your SSN

Parish where you currently live: *

Primary Phone Number: *

Alternate Phone Number:

Email Address that is checked often: *

Phone Number that is available to receive Text Message:

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* 2. Let us know about potential barriers that might keep you from completing the 5-week training program. What OTHER types of barriers are you concerned about:

Reliable transportation to get to and from school or to STPH after you are hired

Dependable Childcare

Other (please specify)

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* 3. If you are currently working, please answer the following

Position Title (Type NONE if not currently working):

Average Hours/Week:

Hourly Rate of Pay:

How long have you been in this position:

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* 4. Please answer the following questions to assist us in determining your eligibility as a "dislocated worker" Please answer each question carefully and accurately.

	Yes	No
Are you a recently separated veteran?	Are you a recently separated veteran? Yes	Are you a recently separated veteran? No
Are you the surviving spouse of a veteran who is eligible for VA benefits?	Are you the surviving spouse of a veteran who is eligible for VA benefits? Yes	Are you the surviving spouse of a veteran who is eligible for VA benefits? No
Are you receiving or have you exhausted unemployment benefits?	Are you receiving or have you exhausted unemployment benefits? Yes	Are you receiving or have you exhausted unemployment benefits? No
Were you laid off in the last 7 years and now making less wages than before?	Were you laid off in the last 7 years and now making less wages than before? Yes	Were you laid off in the last 7 years and now making less wages than before? No
Did your previous employer close or go out of business?	Did your previous employer close or go out of business? Yes	Did your previous employer close or go out of business? No
Did you work less than 20 hours a week in your last job?	Did you work less than 20 hours a week in your last job? Yes	Did you work less than 20 hours a week in your last job? No
Was your last employer a temporary employment agency?	Was your last employer a temporary employment agency? Yes	Was your last employer a temporary employment agency? No
Are you unlikely to return to your previous occupation with the skills you currently have?	Are you unlikely to return to your previous occupation with the skills you currently have? Yes	Are you unlikely to return to your previous occupation with the skills you currently have? No
Were you self-employed, but the economy or a natural disaster has put you out of business?	Were you self-employed, but the economy or a natural disaster has put you out of business? Yes	Were you self-employed, but the economy or a natural disaster has put you out of business? No
Was your previous employment significantly impacted by COVID or Hurricane Ida?	Was your previous employment significantly impacted by COVID or Hurricane Ida? Yes	Was your previous employment significantly impacted by COVID or Hurricane Ida? No
Have you been dependent on the income of another family member and are no longer supported by that income; and are unemployed or underemployed and experiencing difficulty in obtaining or upgrading employment?	Have you been dependent on the income of another family member and are no longer supported by that income; and are unemployed or underemployed and experiencing difficulty in obtaining or upgrading employment? Yes	Have you been dependent on the income of another family member and are no longer supported by that income; and are unemployed or underemployed and experiencing difficulty in obtaining or upgrading employment? No

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* 5. If you indicated that you were LAID-OFF or had reduced wages to due to COVID or Hurricane Ida or prior to COVID and to no fault of your own, please tell us the:

Name of the employer

Month/Year of lay-off

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* 6. If you indicated that you are a recently separated veteran, please indicate your date of separation.

Date of separation:

Date

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* 7. Please complete the following for additional eligibility consideration:

	Yes	No
Do you or someone in your household receive Food Stamps (SNAP):	Do you or someone in your household receive Food Stamps (SNAP): Yes	Do you or someone in your household receive Food Stamps (SNAP): No
Do you or someone in your household receive Welfare Assistance (TANF):	Do you or someone in your household receive Welfare Assistance (TANF): Yes	Do you or someone in your household receive Welfare Assistance (TANF): No
Are you over 18, but under 25?	Are you over 18, but under 25? Yes	Are you over 18, but under 25? No

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* 8. Please complete the following for additional eligibility consideration:

Number of family members in household (including yourself):

Approximate household gross income for the past 6 months (includes all contributing members of the household):

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* 9. I certify that the information provided is true and accurate to the best of my knowledge. Please enter today's date

Today's date:

Date

Thank you for completing the pre-eligibility application.

NEXT STEPS: You will be called and/or emailed to set up for your math/writing assessment and one-on-one pre-screening interview at the Tri-Parish Works Center in Slidell. You will need to provide the following documentation:
> Valid Driver's License or State ID
> Social Security Card
> Employment history, including dates of employment
> If a male over the age of 18, Selective Service verification
> If a veteran, DD-214
> Additional documentation to verify eligibility will also be requested

Note: Please register or update your information in HiRE at www.Louisianaworks.net. The more up-to-date and complete this information is, the more quickly we can process your eligibility determination.
Eligible candidates will then be invited to a phone interview and then a panel interview directly with Ochsner.

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* 10. THIS IS PART OF YOUR ASSESSMENT - TAKE YOUR TIME AND PROOFREAD BEFORE CLICKING DONE.

Please write a short answer (1-3 complete sentences): What do you think are two important qualities to be a great employee at St. Tammany parish Hospital?

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* 11. The COVID-19 Vaccine is required for the clinical portion of the training, without exception. Are you vaccinated or will you at least have your first shot by November 15th (the start of the program)?

Yes

Not Sure

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* 1. Please provide the following contact information

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* 2. Let us know about potential barriers that might keep you from completing the 5-week training program. What OTHER types of barriers are you concerned about:

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* 3. If you are currently working, please answer the following

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* 4. Please answer the following questions to assist us in determining your eligibility as a "dislocated worker" Please answer each question carefully and accurately.

Question Title

* 5. If you indicated that you were LAID-OFF or had reduced wages to due to COVID or Hurricane Ida or prior to COVID and to no fault of your own, please tell us the:

Question Title

* 6. If you indicated that you are a recently separated veteran, please indicate your date of separation.

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* 7. Please complete the following for additional eligibility consideration:

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* 8. Please complete the following for additional eligibility consideration:

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* 9. I certify that the information provided is true and accurate to the best of my knowledge. Please enter today's date

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* 10. THIS IS PART OF YOUR ASSESSMENT - TAKE YOUR TIME AND PROOFREAD BEFORE CLICKING DONE. Please write a short answer (1-3 complete sentences): What do you think are two important qualities to be a great employee at St. Tammany parish Hospital?

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* 11. The COVID-19 Vaccine is required for the clinical portion of the training, without exception. Are you vaccinated or will you at least have your first shot by November 15th (the start of the program)?

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* 12. How did you hear about the program?

* 10. THIS IS PART OF YOUR ASSESSMENT - TAKE YOUR TIME AND PROOFREAD BEFORE CLICKING DONE.

Please write a short answer (1-3 complete sentences): What do you think are two important qualities to be a great employee at St. Tammany parish Hospital?