Employment Focused Needs Assessment Form - Halton Multicultural Council

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Employment Focused Needs Assessment Form

Note
Please complete ALL FIELDS. As HMC Connections is funded in part by Immigration, Refugees and Citizenship Canada (IRCC), your personal information is required in order to measure, evaluate, and meet accountability obligations to Parliament and the Canadian public and is administered in accordance with the Privacy Act (R.S.C., 1985, c. P-21). You have a right under the Access to Information Act (R.S.C., 1985, c. A-1) to obtain access to that information from Canada. Additional information collected by HMC Connections is to support the HMC employment team in assisting you to achieve successful outcomes towards your employment goals and to continuously improve on our program service delivery.
Client Information
Date*
Month
Day
Year
Name*
First Last Preferred Name
Phone*
Voicemail set up?
- Yes
- No
Email*
Emergency Person
Name Phone Relationship
Language CLB Level (if known):*
Are you currently working?
- Yes
- No
If yes, where do you work?
How many hours of work per week?
If no, how long have you been unemployed?
Are you currently studying?
- Yes
- No
If yes, please check what type(s):
- LINC/ESL
- High School
- Alternative School
- Trade School
- College/University
- University
- Other
Hidden
If no, would you be interested in signing up for weekly classes to improve your language skills?
- Yes
- No
Hidden
If yes, when?
Education and Training
Skip if resume is up-to-date
High School Name:
Country of Institution:
From To
Did you graduate?
- Yes
- No
Highest Level Completed:
College Name:
Country of Institution:
From To
Did you graduate?
- Yes
- No
Diploma/Cert. Type or Highest Level Completed:
University Name:
Country of Institution:
From To
Did you graduate?
- Yes
- No
Diploma/Cert. Type or Highest Level Completed:
Other/Certification Bodies:
Country of Institution:
From To
Are you a registered member?
- Yes
- No
Level/Class:
Work History
Skip section if resume is up-to-date
Company
Job Title*
Address
Wage/Salary
From To
Reason for Leaving:
Responisiblities:
Company
Job Title*
Address
Wage/Salary
From To
From To
Reason for Leaving:
Responisiblities:
Employment Preferences
What is your employment area of interest(s) (i.e. sectors and/or industries)?
Job #1
Employment Type
- Full-time
- Part-time
- Contract
- Casual/On-Call
Wage per hour/Salary range:
Job #2
Employment Type
- Full-time
- Part-time
- Contract
- Casual/On-Call
Wage per hour/Salary range:
Job #3
Employment Type
- Full-time
- Part-time
- Contract
- Casual/On-Call
Wage per hour/Salary range:
Have you been applying for the above jobs for the past 3 weeks?
- Yes
- No
If yes, where did you apply, when and how did you apply?
What has your feedback been like? Have you had interviews or offers?
What hours are you available to work?
Earliest Start Time Latest Finish Time
Saturday
- Yes
- No
Sunday
- Yes
- No
Additional notes about availability:
Do you have a bank account set up for direct deposit?
- Yes
- No
Do you have interview clothing?
- Yes
- No
Do you have a valid driver’s license?
- Yes
- No
Driver’s license class:
- G
- G1
- G2
Do you have a vehicle available for work?
- Yes
- No
If commuting by transit, do you have a monthly pass?
- Yes
- No
How far are you willing to travel (one way)?
- 15-20 Mins
- 30 Mins
- 1 hr
- 1.5 hr
- 2 hrs
- 2.5 hrs
- Other
Are you currently set up for remote work/learning?
- Yes
- No
If no, indicate needs:
Are you willing to relocate to another city for the job?
- Yes
- No
Would any of the following situations stop you from starting and/or maintaining a new job in the next coming weeks?
- Scheduled vacation plan/leaving the country
- Family issues
- Religious observances
- Childcare/Dependent Care Obligations
- Financial hardship
- Legal/Court Matters
- Moving/Relocating
- Other
Do you have any restrictions and/or accommodation needs (food handling – due to allergies, vegetarian/vegan, religious observances, health problems, development disability, physical limitations – heavy lifting, standing etc.)?
Languages Fluent In:
Resume & Employment Readiness Check
What areas might you need help with?
- Resume Creation
- Resume/Cover Letter Critique/Updating
- nterview skills
- Job Contacts and Networking
- Career Exploration
- Skilled Trades and Apprenticeships
- Volunteer opportunities
- Job Search Strategizing
- Identifying transferable skills
- Labour Market Research (i.e. pay range, future opportunities)
- Developing positive work references
- Developing positive work references Information on professional development courses
- Information on occupational training programs
- Other
Have you completed a SMART goal exercise?
- Yes
- No
Have you completed a workplace values exercise?
- Yes
- No
Have you participated in any Canadian workplace culture training/workshops?
- Yes
- No
If you had to reflect honestly, is there any reason(s) why an employer might not hire or keep you employed?
- Criminal record
- Age
- Lack of confidence speaking official language
- No professional work references
- Limited understanding of workplace expectations
- Punctuality and time management issues
- Inconsistent attendance
- Difficulty following company rules/procedures
- No previous work experience
- Inconsistent/sporadic work history
- Lost job due to workplace conflict
- Limited interpersonal and/or teamwork skills
- Health conditions/physical limitations
- Past issues with quality of work output
- Finding consistent motivation to go to work
- Difficulty accepting management feedback
- Other
Client Partnership Questions
We will do our best to guide you towards achieving your employment goals and connecting you to potential opportunities. Do you agree to learn how to conduct your own successful job search with our coaching and that it is ultimately your decision to accept the terms of any employment agreement provided to you?
- Yes
- No
Do you give us permission to edit and send your resume and cover letter to a prospective employer?
- Yes
- No
If it is a position we connected you with, do you agree to notify staff if you have any concerns and/or questions about the interview process or meeting (either in-person, phone or virtual) and if you need to reschedule or cancel an interview to let staff know a minimum of 2 hours in advance?
- Yes
- No
As this is a partnership, if you receive an employment offer whether it is through our agency or on your own, do you agree to let HMC staff know the details? For example, company name, company location, company telephone number and/or email, contact person’s name and title, starting date, and wages/salary.
- Yes
- No
CONSENT FOR RELEASE OF INFORMATION*
I, hereby authorize the HMC Connections to exchange & disclose my information internally with HMC programs. I have asked HMC for assistance and give full permission to disclose my personal information (if required) to IRCC & other applicable Service Providers for support, guidance, advocacy, information or referrals.
- Yes
- No
SIGNATURES
Date*
DD slash MM slash YYYY
Signatures*
By typing my name below, I confirm that I have read and understood the information above.

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