KPACE Referral Screening Tool

This assessment tool is intended to assist in the screening of potential applicants for the KPACE program. Please fill out as completely as possible and add comments when applicable. Use the numerical values for each question to determine a total at the end of the assessment. This tool will be used to determine eligibility for the KPACE program.

Date: Referring Agency/Staff email/phone:

Client Name: Best way to reach client? (email, cell phone, home phone) Primary: Secondary: Please list any agencies that are currently assisting the client: (Example: DHS, Young Parents Network, 6th Judicial District, etc.)

Circle Cohort Interest:

Welding

Nurse Aide

Business Computing YES NO

Eligibility Criteria Questions: Are you at least 17 years old? Are you a resident of Benton, Cedar, Iowa, Jones, Johnson, Linn or Washington county? Are you currently employed?

Instructions: Complete this form for entry into the KPACE program. Select one level in each of the areas below by circling the number next to the appropriate level.
A. Income 0) 1) 2) 3) 4) 5) Comments: B. Employment 0) Job status unknown 1) No job 2) Temporary, part-time or seasonal employment 3) Employed full-time; inadequate pay with few or no benefits 4) Employed full-time with adequate pay and benefits 5) Maintains permanent employment with adequate pay and benefits Comments: Income unknown No income Inadequate income Can meet basic needs with subsidy Can meet basic needs but finances not well managed Income is sufficient, well managed

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Adapted from Project ARIBBA Individual Service Strategy Adapted from Rural Arizona HMIS Self-Sufficiency Matrix

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Shelter 0) 1) 2) 3) 4) 5) Housing status unknown Homeless or threatened with eviction In transitional, temporary or substandard housing; current rent/mortgage is unaffordable In stable housing that is safe but only marginally adequate Household is safe, adequate, subsidized housing Household is safe, adequate, unsubsidized housing

Comments: D. Food 0) 1) 2) 3) 4) 5) Comments: E. Childcare 0) 1) 2) 3) 4) 5) Comments: F. Education 0) 1) 2) 3) 4) 5) Comments: Unknown No food or means to prepare it. Relies on sources of free or low-cost food Household is on food stamps Can meet basic food needs but requires occasional assistance Can meet basic food needs without assistance Can choose to purchase any food household desires

Unknown Needs childcare, but none is available/accessible or child is not eligible Childcare is unreliable or unaffordable Affordable subsidized childcare is available but limited Reliable, affordable childcare is available; no need for subsidies Able to select quality childcare of choice or has no children

Education status unknown Literacy problems and/or no high school diploma/GED are serious barriers to employment Enrolled in literacy and/or GED program Has high school diploma/GED Needs additional education/training to improve employment situation Has completed education/training needed to become employable

G. Transportation 0) Transportation status unknown 1) No access to transportation, public or private 2) Transportation is available but unreliable, unpredictable, unaffordable 3) Transportation is available and reliable but limited and/or inconvenient 4) Transportation is generally accessible to meet basic travel needs 5) Transportation is readily available and affordable Comments:

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Adapted from Project ARIBBA Individual Service Strategy Adapted from Rural Arizona HMIS Self-Sufficiency Matrix

H. Behavioral Considerations/Motivation 0) Unknown 1) Dependent on others for information and assistance; poor follow-through 2) Seeks out information and assistance but inconsistent follow-through 3) Calls for help when needed; adequate level of motivation 4) Willingness to learn and utilize resources; consistent follow-through and motivation 5) Highly motivated; independent and committed to improvement Comments: I. Mental Health 0) Unknown 1) Has a diagnosed mental health issue that would absolutely interefere with training. Class attendence and completing assigned work would be a significant challenge. 2) Has a diagnosed mental health issue that could interfere with training. Individual is not accessing or receiving all needed mental health services. Class attendance and completing assigned work could be an issue. 3) May have a mental health issue but has not been diagnosed. Some concern that the individuals presenting issues could interfere with training. Class attendance and completing assigned work would not likely be an issue. 4) Has a diagnosed mental health issue, however, is well managed and would not interfere with training. 5) No mental health issues that would interfere with training. Comments:

Please add up the numerical value of each score indicated and enter score here: ____________ (If any category received a zero score due to unknown status, please proceed with referral. The KPACE Pathway Navigator will follow up with the client to review appropriateness for the program.) Based on the score indicated above, please use the scoring matrix to determine the clients eligibility for the KPACE program. Please fax the completed assessment tool to Mialisa Wright at 319-398-1049 or scan and send to mialisa.wright@kirkwood.edu. Confirmation of receipt will be sent within 5 days.

Scoring Matrix Score: 35-45 Score: 23-34 Very strong candidate. Good Candidate for program. Please refer to KPACE program by Please contact Bethany Parker to faxing or scanning this document discuss potential barriers and Fax:319-398-1049 or extenuating circumstances mialisa.wright@kirkwood.edu mialisa.wright@kirkwood.edu or 319-784-1518. Attn: Mialisa Wright

Score: 12-23 Questionable candidate at this time. May need extensive support services in order to succeed in this program. Please contact Bethany Parker if you feel this candidate has potential to succeed that is not reflected in their score.
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Score: 1-11 Do not refer to program. This client has too many financial and/or personal barriers to succeed in this program at this time. Re-assess eligibility in 6 months.

Adapted from Project ARIBBA Individual Service Strategy Adapted from Rural Arizona HMIS Self-Sufficiency Matrix

1. 2.

Adapted from Project ARIBBA Individual Service Strategy Adapted from Rural Arizona HMIS Self-Sufficiency Matrix