* 1. Name or Initials

* 2. Gender?

* 3. What is your age?

* 4. Residence

* 5. Transportation

* 6. Education (Highest level completed)

* 7. Mental health/addictions Support Information

* 8. Sources of Income

* 9. PENSION: Do you have a concern that employment earnings would/could cause an adjustment in the amount of CPP/ODSP/OW/EI/Other you receieved?

* 10. PENSION: Has anyone ever discussed with you how your earnings can affect your CPP/ODSP/OW/EI/Other earnings?

* 11. PENSION; Did you know that if you received ODSP, you can qualify to get start-up funds if you are looking for employment. You may also qualify for a monthly Employment related Benefit if you have earnings?

* 12. PENSION: Has anyone ever discussed with you the employment opportunities through ODSP Employment SUpports (CPP)?

* 13. EMPLOYMENT HISTORY: Have you been competitively employed on a full-time/part-time basis?

* 14. Have you ever owned and operated your own business? (including family business)

* 15. In what areas have you been employed?

* 16. What kind of position did you hold?

* 17. Why did you leave your last position?

* 18. Are you presently employed?

* 19. Are you attending a skill development program?

* 20. If you are not working, how long have you been unemployed?

* 21. EMPLOYMENT INTEREST - (with support) Are you interested in obtaining some form of competitive employment?

* 22. Are you interested in volunteering as a step towards employment?

* 23. Do you feel taking part in an educational program would be a positive step towards competitive employment?

* 24. Have you ever used the services of these employment agencies/programs?

* 25. What amount of time would you feel comfortable "initially dedicating to employment?

* 26. What amount of time would you feel comfortable "working up to"?

* 27. In which areas would you be interested in obtaining employment?

* 28. EMPLOYMENT SUPPORT- In order for you to prepare for employment, what services do you feel would assist you in this undertaking? (Check as many as required)

* 29. Do you have a current resume?

* 30. Once you have obtained employment, are there specific supports you feel you may require in order to encourage a successful employment experience?

* 31. Can you identify any personal barriers to employment?

* 32. Please list any barriers in order of concern

* 33. Do you feel, with support, a solution can be developed to minimize these barriers?

* 34. Please list a solution that could be developed to minimize these personal barriers to employment.

* 35. Would you like to be presented with options for employment supports in order for you to make an informed decision on employment programs and opportunities?

* 36. COMMUNICATION AND TECHNOLOGY
In order for a potential employer to contact you, do you have:
(a) Access to a regular land line (telephone)

* 37. A cell phone for calling

* 38. A cell phone for texting

* 39. Mobile e-mailing

* 40. A home computer with internet and e-mail access?

* 41. Is it difficult to have the funds for a cell phone, computer, internet?

* 42. Do you own a working, up to date computer?

* 43. Do you know how to use the computer to access the internet, send emails, write documents?

* 44. Would you like help learning how to use the computer, access the internet, send emails, etc.

* 45. Other Issues- Are there any other issues in your life that you could use some help/support with?
ex:Finances, housing, legal, physical health, family

* 46. Interviewee General Comments:

* 47. Interviewer General Comments:

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