Veteran Intake Form

Notice To Our Customers: We are requesting this information to best meet your employment and training needs. We will keep all information you provide to us confidential to the greatest extent allowed by law. If you do not provide this information, you will not be subjected to any adverse treatment.

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Are you interested in receiving one-on-one career planning or help finding employment?

If Yes, please complete this tool to determine whether you are eligible for DVOP specialist services. If No, please stop here; you may be eligible for priority of service from another staff member.

Section A: Current Service Members

If you are currently serving on active duty, select any statements that apply to you.

I am wounded, ill, or injured AND I am receiving treatment at a military treatment facility or soldier recovery unit.
I am within 1 year of separation or 2 years of retirement, AND I have participated in a part of the Transition Assistance Program (TAP).

If you checked any of these, a DVOP specialist can serve you, pending availability; please skip to Section E: Customer Signature. Otherwise, please continue to Section B.

Section B: Eligible Veterans

If you have ever served in the military, select any statements that apply to your service:

I served on active duty for more than 180 consecutive days and was discharged with other than a dishonorable discharge. (ForNational Guard/Reserve, active-duty training does not count toward the 180 days.)
I was released from active duty because of a service-connected disability.
I was released from active duty by reason of a sole survivorship discharge.
I was a member of a Guard/Reserve component; AND served on active duty during a period of war or in a campaign or expedition forwhich a campaign badge is authorized, AND was discharged or released from such duty with other than a dishonorable discharge.

If you checked any of these, you are considered an Eligible Veteran; please skip to Section D to determine whether a DVOP specialist can serve you. Otherwise, please continue to Section C.

Section C: Eligible Persons

If you are the spouse, family caregiver, or widow(er) of someone who served or is serving in the Armed Forces, select any of the following statements that apply to you:

I am the spouse or family caregiver of a wounded, ill, or injured current service member who is receiving care at a military treatmentfacility.

If you checked the box above, a DVOP specialist can serve you; skip to Section E. Otherwise, please continue:

My spouse was a veteran who died because of a service-connected disability.
My spouse has (or my deceased spouse had) a total and permanent service-connected disability rating from the Department of Veterans Affairs.
My active-duty spouse is listed as one of the following, and has been for more than 90 days: 1) missing in action; 2) captured in theline of duty by a hostile force; or 3) forcibly detained or interned in line of duty by a foreign government power.

If you checked any of the boxes in this part of Section C, you are an Eligible Person; please continue to Section D to determine whether a DVOP specialist can serve you. Otherwise, please stop here; you may be eligible for priority of service from another staff member.

Section D: Qualifying Situations

Only complete this section if directed by either Section B: Eligible Veterans or Section C: Eligible Persons. Select any of the statements that apply to you.

I have a disability, which may include any of the following:

I am entitled to compensation for a service-connected disability from the U.S. Department of Veterans Affairs (VA), or I currently have a disability claim pending with the VA.
I was released from active duty due to a service-connected disability.
I have another disability, meaning a physical or mental impairment that substantially limits one or more major life activities.

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I am experiencing homelessness, including any of the following:

I served in the Republic of Vietnam at any time between November 1, 1955, and May 7, 1975, or
Any part of my active duty service was between August 5, 1964, and May 7, 1975.

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I am an Eligible Veteran, and I was discharged or released from active duty within the last three years.
I have been referred for employment services by a representative of the U.S. Department of Veterans Affairs.

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I am experiencing homelessness, including any of the following:

I do not have (and cannot obtain) a fixed, regular, adequate, permanent place to live.
I will soon lose my housing and do not have anywhere else to go.
I am attempting to flee domestic violence and have no safe residence or resources to obtain safe permanent housing

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I have been subjected to any stage of the criminal justice process, and/or I need assistance overcoming employment barriers resultingfrom a record of arrest or conviction.
I am between 18–24 years of age.
I do not have a high school diploma or equivalent certificate.
receive (or have in the last 6 months received) public assistance through SNAP, TANF, SSI, or state or local income-based programs.
My total family income does not exceed the higher of the poverty line, or 70% of the lower living standard income level.(Please ask for assistance if you think it might apply to you.)
I am unemployed and am available to work.
I am the head of a single-parent household.

Section E: Customer Signature

If directed here from a previous section, you are eligible for DVOP specialist services based on your responses. By completing these fields, you certify that your answers are true to the best of your knowledge.

Name

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Last

Phone

Date