Customer Information by HC120521012518

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									                                              Trade Adjustment Assistance
                                                    Individual Employment Plan (IEP)
                                                                Customer Information

    1. LWIA #:                                           2. Customer SSN:                      3. Application Date:         /       /
    4. Last Name:                                                        First Name:                           Middle Initial:
    5. Street Address (Residence):                                                                             Apt.:
    6. City:                                                            7. State:                 8. Zip:
    9. Phone Number(s): Home (                 )    -                   Work (      )   -       ext.           Cell (       )           -
    10. Email:                                                                      11. County (for in-state addresses):


    STAFF USE ONLY
    12. TAA Petition Number:                             13. Employer Name:

                                                                 Employment Goal

    14. Employment Goal:

    15. Wage Expectation: $                   per       hour     month                      16. Distance Willing to Travel:                         miles

    17. Employment Assistance (Indicate the type(s) of assistance the customer needs to reach employment goal):

                    Registration with Illinois Skills Match                                            Date Goal Reached:                   /   /
                    Registration with Illinois workNet                                                 Date Goal Reached:                   /   /
                    Resume/Cover Letters Workshops                                                     Date Goal Reached:                   /   /
                    Job Search Assistance Workshops                                                    Date Goal Reached:                   /   /
                    Interviewing Skills Workshops                                                      Date Goal Reached:                   /   /
                    Computer Skills Workshops                                                          Date Goal Reached:                   /   /
                    List Additional Assistance:                                                        Date Goal Reached:                   /   /
                    List Additional Assistance:                                                        Date Goal Reached:                   /   /

                                                                Employment History
                                                           (List most recent Employer First)
                 18. Name of Employer:                                                      19. Job Title:
                 20. Contact Name:                                                          21. Phone Number: (         )       -           Ext.:
                 22. Street Address:                                                        PO Box:
Work History 1




                 23. City:                                                                  24. State:                              25. Zip:
                 26. Employment Start Date:         /     /         28. Avg. Hours Worked per               29. Ending Wage: $                       per
                                                                        Week:
                 27. Employment End Date :          /     /                                                        hour                 week         month

                 30. Did you Supervise employees:         Yes      No               31. If Yes, how many:
                 32. Describe your duties and responsibilities for each Job Title held:




                 Revised June 2009                                  Page 1 of 8                                         DCEO/TAA Form #014
                                             Trade Adjustment Assistance
                                                   Individual Employment Plan (IEP)

                 18. Name of Employer:                                                19. Job Title:
                 20. Contact Name:                                                    21. Phone Number: (     )    -       Ext.:
                 22. Street Address:                                                  PO Box:
Work History 2




                 23. City:                                                            24. State:                       25. Zip:
                 26. Employment Start Date:        /    /         28. Avg. Hours Worked per        29. Ending Wage: $              per
                                                                      Week:
                 27. Employment End Date :         /    /                                                   hour       week        month

                 30. Did you Supervise employees:       Yes      No             31. If Yes, how many:
                 32. Describe your duties and responsibilities for each Job Title held:




                 18. Name of Employer:                                                19. Job Title:
                 20. Contact Name:                                                    21. Phone Number: (     )    -       Ext.:
                 22. Street Address:                                                  PO Box:
Work History 3




                 23. City:                                                            24. State:                       25. Zip:
                 26. Employment Start Date:        /    /         28. Avg. Hours Worked per        29. Ending Wage: $              per
                                                                      Week:
                 27. Employment End Date :         /    /                                                   hour       week        month

                 30. Did you Supervise employees:       Yes      No             31. If Yes, how many:
                 32. Describe your duties and responsibilities for each Job Title held:




                                                            Occupational Information
    33. Transferable Skills (List all Skills that can be applied in a variety of Occupations and Job Titles):




    34. Barriers to Employment / Supportive Services Needed for Employment (Barriers to Employment are anything that
        can impede the customer’s chances at obtaining suitable employment. Barriers can include legal, health, physical
        limitations, transportation, day care, housing, educational, etc):




                 Describe:



                  Revised June 2009                               Page 2 of 8                                 DCEO/TAA Form #014
                                            Trade Adjustment Assistance
                                                  Individual Employment Plan (IEP)
                                                                Testing and Assessment

35. List All Tests/Assessment Completed:

36. Copy(s) of completed test/assessment are attached:                            Yes        No. If no explain why.

37. Reading Score:                    Date Completed:                 /      /          38. Math Score:        Date Completed:                    /   /

39. Other Test Name:                                                                    40. Other Test Score/Result:




                                                                 Education Information
School




                 41. High School Graduate:                Yes        No                        42. Number of Years Completed:
 /GED
 High




                 43. GED:       Yes      No               N/A If Yes, Date Completed:              /      /

                 44. Business/Trade School Name:                                               45. Address:
 Trade School
  Business/




                 46. City:                                                                     47. State:             48. Zip:                -
                 49. Training Start Date:     /       /                                        50. Training End Date:         /       /
                 51. List Degree/Certificate Obtained:                                         52. Course of Study:

                 53. College Name:                                                             54. Address:
 Undergraduate




                 55. City:                                                                     56. State:             57. Zip:                -
   College -




                 58. College Graduate:        Yes               No                             59. Number of Years Completed:
                 60. Training Start Date:     /       /                                        61. Training End Date      /       /
                 62. Credit Hours Earned:                                                      63. Major Course of Study:
                 64. Minor Course of Study:                                                    65. List Degree/Certificate Obtained:

                 66. College Name:                                                             67. Address:
                 68. City:                                                                     69. State:             70. Zip:                -
 Graduate
 College -




                 71. College Graduate:        Yes               No                             72. Number of Years Completed:
                 73. Training Start Date:         /       /                                    74. Training End Date:             /       /
                 75. Credit Hours Earned:                                                      76. Course of Study:
                 77. Additional Course of Study:                                               78. List Degree/Certificate Obtained:




            Revised June 2009                                             Page 3 of 8                                     DCEO/TAA Form #014
                                                                 Trade Adjustment Assistance
                                                                          Individual Employment Plan (IEP)

                                                                                  Training Information
                                       79. List/Describe Customer’s Training Goal(s):
 Training Goal




                                      80. Remedial Program Name:

                                       81. Training Institution Name:

                                      82. Address:
Remedial Training Plan




                                      83. City:                                                84. State:                     85. Zip:                      -

                                      86. Training Start Date:    /       /                    87. Training Planned End Date:               /       /

                                      88. Total Weeks of Remedial Training:                    89. Date Training Approved:      /       /

                                      90. Cost of Remedial Training: $                         91. Funding Source:

                                      92. Documentation of Full Time Status:                                                                                Yes     No

                                      93. Is the Completed Verification of Training Form(s) Attached to this Training Plan?                                 Yes     No

                                      94. Is the Completed Eligibility For Transportation Form(s) Attached to this Training Plan?                           Yes     No

                                      95. Is the Program Course Description/Schedule From the Training Institution Attached?                                Yes     No


                                      96. Remedial Program Name:

                                      97. Training Institution Name:
Additional Remedial Training Plan




                                      98. Address:

                                      99. City:                                                100. State:                    101. Zip:                         -

                                      102. Training Start Date:       /       /                103. Training Planned End Date:                  /       /

                                      104. Total Weeks of Remedial Training:                   105. Date Training Approved:         /       /

                                      106. Cost of Remedial Training: $                        107. Funding Source:

                                      108. Documentation of Full Time Status:                                                                               Yes     No

                                      109. Is the Completed Verification of Training Form(s) Attached to this Training Plan?                                Yes     No

                                      110. Is the Completed Eligibility For Transportation Form(s) Attached to this Training Plan?                          Yes     No

                                      111. Is the Program Course Description/Schedule From the Training Institution Attached?                               Yes     No



                                    Revised June 2009                                Page 4 of 8                                    DCEO/TAA Form #014
                                                       Trade Adjustment Assistance
                                                                Individual Employment Plan (IEP)

                                                                     Training Information (cont.)

                               112. Vocational Program Name:

                               113. Training Institution Name:

                               114. Address:

                               115. City:                                              116. State:                    117. Zip:            -
  Vocational Training Plan




                               118. Training Start Date:    /    /                     119. Training Planned End Date:           /   /

                               120. Total Weeks of Vocational Training:                121. Date Training Approved:      /   /

                               122. Cost of Vocational Training: $                     123. Funding Source:

                               124. Documentation of Full Time Status:                                                                   Yes   No

                               125. Is the Completed Verification of Training Form(s) Attached to this Training Plan?                    Yes   No

                               126. Is the Completed Eligibility For Transportation Form(s) Attached to this Training Plan?              Yes   No

                               127. Is the Program Course Description/Schedule From the Training Institution Attached?                   Yes   No

                               128. Is LMI supporting the training choice attached?                                                      Yes   No


                                129. Total Number of Remedial Training Weeks:
Training
 Total

  Plan




                                130. Total Number of Vocational Training Weeks:

                                131. Customer’s Total Training Weeks:

                                132. Are there any Breaks in Training longer than 30
                                     Training Days that occur during the customer's          Yes      No If yes, complete #133 - #150
                                     TRA Benefit Period?
                                133. Date Break Begins:          134. Date Break Ends:
                                                                                               135. Number of Days not Payable TRA:
                                       / /                              / /

                                136. Date Break Begins:          137. Date Break Ends:
                                                                                               138. Number of Days not Payable TRA:
                                       / /                              / /
   Training Breaks




                                139. Date Break Begins:          140. Date Break Ends:
                                                                                               141. Number of Days not Payable TRA:
                                       / /                              / /

                                142. Date Break Begins:          143. Date Break Ends:
                                                                                               144. Number of Days not Payable TRA:
                                       / /                              / /

                                145. Date Break Begins:          146. Date Break Ends:
                                                                                               147. Number of Days not Payable TRA:
                                       / /                              / /

                                148. Date Break Begins:          149. Date Break Ends:
                                                                                               150. Number of Days not Payable TRA:
                                       / /                              / /



                             Revised June 2009                              Page 5 of 8                                  DCEO/TAA Form #014
                                                                   Trade Adjustment Assistance
                                                                        Individual Employment Plan (IEP)

                                                                              Training Information (cont.)
                                           151. There is no suitable employment (which may include technical and professional
                                                employment) available for an adversely affected worker. Describe how this condition
                                                has been met: (Condition 1)                                                                 Yes     No


                                           152. The worker would benefit from appropriate training. Describe how this condition has
                                                been met: (Condition 2)
                                                                                                                                            Yes     No


                                           153. There is a reasonable expectation of employment following completion of such training.
                                                Describe how this condition has been met: (Condition 3)
                                                                                                                                            Yes     No
  Conditions for Approval of Training




                                           154. Training is reasonably available to the worker. Describe how this condition has been
                                                met: (Condition 4)
                                                                                                                                            Yes     No


                                           155. The worker is qualified to undertake and complete such training. Describe how this
                                                condition has been met: (Condition 5)
                                                                                                                                            Yes     No


                                           156. Such training is suitable for the worker and available at a reasonable cost. Describe
                                                how this condition has been met: (Condition 6)
                                                                                                                                            Yes     No


                                           157. The customer understands that the customer, no family member or friend can
                                                contribute towards the training costs.
                                                                                                                                            Yes     No


                                           158. Describe how you documented that consideration was given to the lowest cost training available within the
                                                commuting area:




                                                                                  Financial Information

159. Is the Completed 210 Form Attached to this Training Plan?                                                                              Yes     No
160. Is the Completed ITA Form(s) Attached to this Training Plan for all trainings?                                                         Yes     No
161. Will the customer have sufficient UI/TRA benefits to cover the complete training period?                                               Yes     No
162. If UI/TRA is not available, has the customer provided documentation demonstrating they have
                                                                                                                                            Yes     No
     the financial ability to complete the agreed upon training plan?




                                        Revised June 2009                              Page 6 of 8                                 DCEO/TAA Form #014
                                                 Trade Adjustment Assistance
                                                       Individual Employment Plan (IEP)

                                                               Original Approval of Plan
 Notice of Certification:
 I certify that the preceding information is correct to the best of my knowledge and that there is no intent to commit fraud.
 163. Customer Signature:                                                                                     Date:     /     /


                                                                          Comments
 164. List Additional Comments:




 STAFF USE ONLY
 165. LWIA Case Manager Signature:                                                                             Date:     /    /

                                                  Pre-Approved Changes to Plan – Change 1
                166. Date of Change: / /                                               167. Date Change to Take Affect:           / /
                168. Describe Reason for Change:


                169. List Documentation to Support Change to Plan:
Plan Change 1




                170. With the Change, will the Customer Complete Training within the allowable 104/130 weeks:                         Yes      No
                     If no, the change is not allowed.
                Notice of Certification:
                I certify that the preceding information is correct to the best of my knowledge and that there is no intent to commit fraud.
                171. Customer Signature:                                                                                Date:     /    /

                172. Case Manager Signature:                                                                            Date:     /    /


                166. Date of Change: / /                                               167. Date Change to Take Affect:           / /
                168. Describe Reason for Change:
Plan Change 2




                169. List Documentation to Support Change to Plan:



                170. With the Change, will the Customer Complete Training within the allowable 104/130 weeks:                         Yes      No
                     If no, the change is not allowed.


                 Revised June 2009                                      Page 7 of 8                                          DCEO/TAA Form #014
                                                  Trade Adjustment Assistance
                                                        Individual Employment Plan (IEP)
                 Notice of Certification:
                 I certify that the preceding information is correct to the best of my knowledge and that there is no intent to commit fraud.
                 171. Customer Signature:                                                                                Date:     /    /
                 172. Case Manager Signature:                                                                            Date:     /    /


                 166. Date of Change: / /                                               167. Date Change to Take Affect:           / /
                 168. Describe Reason for Change:


                 169. List Documentation to Support Change to Plan:
 Plan Change 3




                 170. With the Change, will the Customer Complete Training within the allowable 104/130 weeks:                         Yes      No
                      If no, the change is not allowed.
                 Notice of Certification:
                 I certify that the preceding information is correct to the best of my knowledge and that there is no intent to commit fraud.
                 171. Customer Signature:                                                                                Date:     /    /

                 172. Case Manager Signature:                                                                            Date:     /    /

                 173. Describe The Type and Reason for Customer Tutoring Assistance
Tutoring




                 Notice of Certification:
                 I certify that the preceding information is correct to the best of my knowledge and that there is no intent to commit fraud.
                 174. Customer Signature:                                                                                Date:     /    /

                 175. Case Manager Signature:                                                                            Date:     /    /


 NOTE: Attach additional sheets if there is a need for more than three (3) Plan Changes.




                  Revised June 2009                                      Page 8 of 8                                       DCEO/TAA Form #014

								
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