Intake Assessment Form (Page 2 of 2) in pdf

STUDENT STATUS and SPECIAL POPULATIONS

*Labor Force Status:

Employed

Unemployed and looking for work

(select one)

Not working and not looking for work (e.g. homemaker, retiree, student, etc.)

*Receiving Public Assistance (TANF, Food Stamps):

Yes

*Special Populations:

Low Income

Displaced Homemaker

Single Parent

Dislocated Worker

Learning Disabled Adult

Physically Disabled Adult

None of the above

(check all that apply)

Language spoken at home: ____________________________ Home Country: _________________________________

STUDENT GOALS

What do you want to achieve by attending the adult education program?

Improve Basic Literacy Skills:

Improve English Language Skills:

Get a job

Reading

Speaking

Keep my job

Math

Listening

Get a better job

Writing

Reading

Earn a GED diploma

Science

Writing

Enroll in college

Social Studies

Enroll in a training program

Please select any other goals you have.

Achieve work-based project learning goal

Achieve ACT WorkKeys Certificate (Georgia goal)

Leave public assistance program

Other _______________________________

Increase involvement in children's education

Increase involvement in children's literacy

English Literacy/Civics Goals

activities

Achieve citizenship skills

Increase involvement in community activities

Achieve U.S. citizenship (Georgia goal)

Vote or register to vote

Special Accommodations Notice

If you have a disability and desire any special accommodation for instruction or testing, it is your responsibility to notify the

program administrative office and provide professional documentation of your disability.

Confidentiality Notice

This adult education program may release your student information for only specific reasons allowed under the Family

Educational Rights and Privacy Act (20 U.S.C. § 1232g; 34 CFR Part 99), such as program evaluation purposes. If you

do not wish this information to be disclosed, please check this box:

*Student’s Signature (ink): ___________________________________________

*Date (ink): __________________

FOR PROGRAM USE ONLY: This section is completed by the interviewer during an initial conference with the student after pre-testing is

completed.

1. What is the student’s

primary reason for

enrolling?

2. What services will the

program provide the

student?

3. What are the student’s

college, career, or

other goals?

*Student’s Signature (ink):

*Date (ink):

*Interviewer’s Signature (ink):

*Date (ink):

Please note: Teachers should conference with the student at least once per quarter. Conference notes must be maintained either in hard copy

format in the student permanent record or in GALIS. More information is available in the Intake Assessment Form Directions and Definitions

document.

Technical College System of Georgia, Office of Adult Education, Intake Assessment Form, Effective: July 1, 2014

Intake Assessment Form Page 2

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