Fillable STNA Packet 1 (Allen County Ohio)

Fill Online, Printable, Fillable, Blank STNA Packet 1 (Allen County Ohio) Form

Use Fill to complete blank online ALLEN COUNTY OHIO pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

STNA Packet 1 (Allen County Ohio)

On average this form takes 55 minutes to complete

The STNA Packet 1 (Allen County Ohio) form is 6 pages long and contains:

  • 0 signatures
  • 47 check-boxes
  • 198 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Allen County Ohio forms online.

BROWSE ALLEN COUNTY OHIO FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
STNA Informational Appointment Checklist
PLEASE READ INFORMATION BELOW:
THIS PACKET MUST BE COMPLETED before you can meet with a Case Manager.
Once you have everything on the checklist completed, please call (419) 999-0360 and ask to schedule an informational appointment.
Please reserve program questions for the Case Manager who will review the checklist with you.
Please ensure you have following items with you when you make appointment with Case Manager.
If not applicable to your situation, please indicate N/A
Documentation needed for you to bring to your scheduled appointment with Case Manager:
Age – Birth certificate, Baptismal Record, DD214, Driver License, OR Passport
Citizenship – Social Security Card, Birth Certificate, Baptismal Record, OR Passport
Social Security Number – Social Security Card, DD214, OR Passport
Selective Service – If male, born after Jan.1, 1960. DD214 or verification of registration (www.sss.gov
)
Dislocated Worker – Layoff letter or Unemployment Compensation Verification
Income – All income for all household members for the last 30 days
Resume – Updated resume
OMJ Employment Contact Form or documentation of your job search for the last 30 days (if unemployed)
OMJ Individual Assessment/Application completed
OMJ Job History Form completed
Information Required for STNA Students
All medical students must verify their background. Verification of this can be found at www.limamunicipalcourt.org or your
local municipal court if not an Allen County resident.
STNA Individual Assessment form completed (included in this package)
PLEASE NOTE: The Workforce Innovation and Opportunity Act (WIOA) is not an entitlement program and you are not
guaranteed career or training services. Your eligibility and suitability for services will be determined by a WIOA Case Manager.
WIOA 900-08/Revised 11/2017
Individual Assessment /Application
READ & COMPLETE CAREFULLY
You will be rescheduled if this form is not completed in its entirety
What type of service are you exploring? Job Search Education/Training On-the-Job Training
Name:
Date:
Mailing Address: City: State: ZIP:
Phone Number:
Email:
Social Security Number:
Are you between the ages of 18 – 24?
Yes
No
Are you a Veteran?
Yes
No
Income Information
List Household Members
(Include yourself)
Relationship Date of Birth
Monthly Income
(Income including: Earned & Unearned Income,
Unemployment Comp, SSI, RSDI, etc)
$
$
$
$
$
$
If no income, how do you support yourself?
Employment Information
Are you currently employed?
Yes
No
If employed, list current place of employment:
Are you presently laid-off?
Yes
No
If yes, list company:
Have you received notification of layoff?
Yes No
If yes, list company:
Career/Education Goal
What is your education status?
HS Grad /GED
ABLE
Vocational School
Associate Degree
Bachelor Degree
Certificate
Credential
Some College ____________________________
If you have not graduated or received your High School Equivalency, what is the highest grade completed?
What is your employment or career goal?
Are you currently enrolled in school?
Yes
No If yes, where/what program:
Where would you like to receive this training?
Did you complete any type of assessment at the training institution or career placement
Yes
No
(Example: WorkKeys, Compass, TABE, SLE)
Cost of this training:
Start date of the training:
Anticipated end date of the training:
What kind of jobs would you be qualified for after completing this training?
What skills, experience or training do you currently have that would make you a good candidate for this field?
What is the entry-level salary/wage rate for jobs in this field?
What is the employment outlook, including projected annual openings, for this type of work in the local job market?
How far are you willing to travel/drive for a position in this field?
Please indicate the Job Search skills that you need assistance with:
Basic Computer Word Excel Internet Job Search Resume Cover Letters Interviewing
Budgeting Other ___________________________________________________________________________________
What will be your job search strategy following the training?
Needs & Barriers
Disabled
Older Worker
Substance Abuse
Limited Proficiency
Offender
Basic Literacy
Learning Disability Poor Work History Homeless TANF Exhausted School Drop-out
Mental/Physical Limitations Past IEP (Individual Education Plan)
Will you need child care now or in the future?
Yes
No
What is your emergency plan when the child(ren) is ill and cannot stay with child care provider?
Can you provide your own transportation?
Yes
No
If no, who will be responsible for driving you back & forth to training/work?
Financial Aid (Education/Training Only)
PELL Amount awarded
$
Employer Scholarship or Contribution
$
Student Loans
$
Other Resources:______________
$
Total Amount Awarded
$
Are you default on a previous Student Loan?
Yes
No
If yes have you been making payments?
Yes
No
**Documentation of last 6 months of on-time payments must be
provided for default student loans
________________________________________________________ ________________________________
Customer Signature Date
________________________________________________________ ________________________________
Case Manager Signature Date
OMJ Form 900-03/Revised 11/2017
STNA Individual Assessment
Below are common job duties of a licensed STNA. Please review this list and check box if you would be
willing and able to perform the job duties.
Dispose of soiled linen
Apply vest restraint
Assists resident with the use of bedpan, commode or bathroom
Dress resident
Feed dependent resident
Give bed bath, tub bath or shower
Make an occupied/unoccupied bed
Measure and record urinary output
Provide denture care
Provide hair care (shampoo, brush/comb, etc.)
Provide mouth care
Provide perinea (skin) care for incontinent resident
Provide routine fingernail care
Provide routine foot care
Shave resident
Transfer resident from bed to wheelchair
Below are common convictions which could disqualify you from becoming a licensed STNA. If you have
been convicted of one of these crimes you may want to reconsider your career decision.
• Aggravated Menacing
• Assault
• Breaking & Entering
• Burglary
• Domestic Violence
• Drug Crimes
• Misuse of Credit Cards
• Pandering Obscenity
• Passing Bad Checks
• Prostitution
• Public Indecency
• Receiving Stolen Property
• Robbery
• Sexual Oriented Crime
• Theft
• Unauthorized use of Property
• Unauthorized use of a vehicle
• Voluntary/Involuntary
Manslaughter
• Weapons Crimes
_______________________________________________ _______________________________
Signature Date
WIOA 900-09/Revised 11/2017
Job History
Name _______________________________________ Last four SSN xxx-xx ___________
List Employment History
* Begin with most current employment
Employer:
City & State:
Hours Worked Per Week:
Start Date: Starting Wage:
End Date: Current/Ending Wage:
Job Duties:
Reason For Leaving:
Employer:
City & State:
Hours Worked Per Week:
Start Date: Starting Wage:
End Date: Current/Ending Wage:
Job Duties:
Reason For Leaving:
Employer:
City & State:
Hours Worked Per Week:
Start Date: Starting Wage:
End Date: Current/Ending Wage:
Job Duties:
Reason For Leaving:
Employer:
City & State:
Hours Worked Per Week:
Start Date: Starting Wage:
End Date: Current/Ending Wage:
Job Duties:
Reason For Leaving:
I have never been employed. Initials__________ Date______________ OMJ Form 900-06/Revised 11/2017
Employer Contacts for the Last 30 days
Date Employer
Application method
(online, in person, etc)
What position did you
apply for?
Do you currently
have the
qualification(s)
for this position?
Response from
Employer
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Signature _________________________________________________ Date _____________________
OMJ Form 900-07/Revised 11/2017
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

STNA Packet 1 (Allen County Ohio)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document