CareerSource Tampa Bay Success Story Submission Form

CSTB Staff or Partner Information

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* 1. Date: (DD/MM/YYYY Format)

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* 2. Staff Name:

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* 3. Staff Title:

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* 4. Staff Email:

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* 5. Office Location

Tampa

Brandon

Plant City

Ruskin

Other (please specify)

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* 6. Partner Agency Only- Name of Partner Agency:

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* 7. Partner Agency Only- Staff POC Email:

Customer Information

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* 8. Customer Name:

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* 9. Customer Phone:

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* 10. Customer Email:

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* 11. Customer Zip Code of Residence

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* 12. Are you a Program Participant or Business/Community Partner

Program Participant

Business/Community Partner

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* 13. Program:

WIOA AD

WIOA DW

WIOA Youth

WTP

SNAP

Tampa Bay Summer Hires

Special Grant

Other (please specify)

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* 14. Secondary Funding (if applicable)

United Way Suncoast

Florida Medical Clinic Foundation of Caring

Other (please specify)

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* 15. Summary of Services Received:

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* 16. Training Provider (if applicable):

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* 17. Training Program (if applicable):

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* 18. Employment Status (Check all that apply):

Employed Full-Time

Employed Part-Time

Self-Employed

Student (Full or Part-Time)

Not Working/Retired

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* 19. If employed, what is the employer name?

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* 20. If employed, what is the job title of the position?

Success Story Summary

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* 21. Briefly summarize the customer's story and outcome in 2-3 sentences.

The Subject

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* 22. Who is the story about? Describe their age, characteristics and other details relevant to the story.

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* 23. Other details relevant to the story?

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* 24. How did they find out about CSTB? Where and when did this occur?

The Story

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* 25. What challenges were they facing? Why did this customer need assistance from CSTB?

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* 26. How did CSTB help?

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* 27. What was the outcome? What did the customer accomplish?

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* 28. What else changed for this person or business? What was the overall impact?

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* 29. Please provide any additional details you think may be important.

Quote or Testimonial

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* 30. Please include a brief quote or testimonial. (Optional)

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* 31. May we use (select one):

The customer's full name and photo

The customer's first name only

The customer's initials only

Generic attribution only (Example: WIOA Participant)

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* 32. Does the customer agree to be interviewed if requested?

Yes