Attachment G
Chapter 4, Part 2 – Program Activities
INDIVIDUAL SERVICE STRATEGY (ISS)
BACKGROUND INFORMATION
Participant Name:
Phone Number:
Date of Enrollment:
Address:
City/State/Zip Code:
Birth date:
Case Manager:
Referral Source/Contact Information: (if applicable)
Educational History
Attending School:
YES
Current Grade Level/#of Credits:
NO
Dropped Out of School:
Highest Grade Completed/# of Credits:
YES
NO
Competed High School Diploma/GED:
Date Completed:
Name of School:
Last School Attended:
School/Program:
YES
NO
If Dropped Out, Why?
Ever Attended Post Secondary School:
School:
Area of Concentration/Study:
YES
NO
List any other Diplomas/Degrees/Licenses/Certifications:
List any additional Educational/Vocational Training Courses taken:
Other Comments on Educational History:
Employment History
Job Title & Duties
Employer
Dates Worked & Reason for Leaving
Describe any other work experience and/or skills learned through volunteering, hobbies, etc:
Other Comments on Employment History:
Revised 7/1/16
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Attachment G
Chapter 4, Part 2 – Program Activities
BARRIERS
Education and Training Barriers:
Low Math/Reading Skills
Dropped out of school
Learning Disability
Attendance
Grades/Credits
Suspensions/Expulsions
English (Speaking/Reading/Writing)
First Generation High School Graduate
No Picture ID
Lack of career goals
Lack of vocational skills
No work history
Poor work references
Comments:
Employment Barriers:
Work Clothing
Equipment/Tools
Criminal History/Record
Comments:
Life skills Barriers:
Housing
Food
Clothing
Transportation
Pregnant/Parenting
Child Care
Healthcare
Driving License
No social security card
Legal Issues
Budgeting
Financial/Credit History
Gang Affected/Involved
Currently in foster care/ward of court
Formerly in foster care/ward of court
Is/was raised by someone other than biological parents
Family Issues/Instability
Parent/Guardian incarcerated
Substance Abuse
Mental Health/Counseling
Self-Esteem
Depression
Motivation
Anger Management
Comments:
Additional Barriers/Comments:
ASSESSMENT RESULTS SUMMARY
Academic Skill Assessments
Name of Test & Version Used:
Pre-Test Score & Date Taken:
Post Test Scores & Date Taken: (if applicable)
Math:
Math:
Reading:
Reading:
Writing:
Writing:
Other Academic Assessment Results/Comments:
Academic Needs/Accommodations (please include any Individual Education Plan [IEP] Information [if applicable]):
Other Assessment Results
Interest/Aptitudes: (please list any tools used to assess)
Career/Employment: (please list any tools used to assess)
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Attachment G
Chapter 4, Part 2 – Program Activities
Life Skills: (please list any tools used to assess)
Other Assessment Results/Comments:
TRAINING PLAN/GOALS
Goal(s):
Steps to Accomplish Goal:
Notes:
(list type of training/services including information on
provider, location, length, etc)
(supportive services needed, training
schedule, referral contacts, etc)
Education Goal(s):
1.
1.
Occupational/Career Goal(s):
1.
1.
Work Readiness Goal (s):
1.
1.
Personal Goal(s):
1.
1.
ISS Summary/Comments:
I understand and agree to the service plan as described. I also understand that this plan does not constitute an entitlement to these services. I
authorize my case manager and/or program staff to communicate pertinent information about me and my goals to any and all agencies, schools, and
employers in order to assist me in meeting my training plan/goals.
Participant Signature
Case Manager Signature
Date
1st
Case Manager Initials
ISS Review/Revision:
2nd ISS Review/Revision:
3rd ISS Review/Revision:
4th ISS Review/Revision:
Revised 7/1/16
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Date
Participant Initials