INDIVIDUAL EMPLOYMENT PLAN (IEP)
Adult Dislocated Worker
Agency: Client Name NV#
Please print.
SECTION 1 – PARTICIPANT IDENTIFICATION
Name: Date:Address: City: State: Zip:
Phone #:
Others Who May Assist in Getting in Touch With Participant for Follow-up:
Name: Relationship:
Address: Phone #:
Name: Relationship:
Address: Phone #:
Education: Student (H.S. or less)
H.S. Graduate Year HSE. Year If not a graduate, highest grade completed
College Graduate Year Degree: A.A./A.S. B.A./B.S. Master’s PhD.
If not a college graduate, # of yrs of college Major
SECTION 2 – WIOA PARTNER/OTHER PROGRAM PARTICIPATION
WIA Title I: Adult Dislocated Worker
Other Partner Programs:
Wagner-Peyser Title V Older Worker Unemployment Insurance Vocational Rehabilitation
HUD E&T CDBG Adult Ed. & Literacy Carl Perkins Post-secondary Voc. Ed.
NAFTA TAA Veterans Welfare-to-Work
Native American Programs Job Corps Migrant Seasonal Farm Workers Veterans Workforce Programs
TANF Food Stamps Other
WIC Parole/Probation Service Other
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SECTION 3 – BARRIERS TO EMPLOYMENT
Check all that apply:BARRIERS BARRIERS
Homeless Basic Skills < 8th grade
Disabled Insufficient Skill for Employment Goals
School Dropout Improvement Needed in Basic Skills
Limited English Proficiency Skills Obsolete
Displaced Homemaker limited Employment Opportunities for Current Skills
Child Care Lack of Employment Seeking Skills…………………………
Offender Driver’s License
Substance Abuse Family Issues
Unemployed Transportation
Underemployed Legal Issues
Poor Work History Health Issues………………………………………………….
SECTION 4 – SUPPORT SERVICES NEEDED
Currently receiving the following Partner Support Services:Partner Name Service Provided
Partner Name Service Provided
Partner Name Service Provided
Partner Name Service Provided
Partner Name Service Provided
Partner Name Service Provided
Non-Training Related Support Services Needed During Program Participation:
(1) (2) (3)
(4) (5) (6)
INDIVIDUAL EMPLOYMENT PLAN (IEP)
Adult Dislocated Worker
Agency: Client Name NV#
CERTIFICATION TRAINING/ OJT TRAINING
PRE-REQUISITES AND SUPPORT SERVICE
SECTION 5 – CERTIFICATION TRAINING GOALS
Certification Training:
Name of ETPL Provider: Training Site: Cost:
Sector: O’Net Code:
Start Date: Targeted Completion Date:
Actual Completion Date:
Pre-Requisite:
Name of Provider: Training Site: Cost:
Start Date: Targeted Completion Date: Actual Completion Date:
Pre-Requisite:
Name of Provider: Training Site: Cost:
Start Date: Targeted Completion Date: Actual Completion Date:
On the Job Training:
(Employer Name)
Employer Address: Contract Amount:
Sector: O’Net Code:
Start Date: Targeted Completion Date:
Actual Completion Date:
Support Services While in Training
Type Cost Date:
Type Cost Date:
Type Cost Date:
Type Cost Date
Type Cost Date
Type Cost Date
Type Cost Date
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SECTION 6 – ADDITIONAL EDUCATION/EMPLOYMENT GOALS
Employment Goal:Goal #1:
Training Program Description: Work Readiness Basic Skills
Name of Provider: Training Site:
Expected Outcome:
Target Completion Date: Actual Completion Date:
Goal #2:
Training Program Description: Work Readiness Basic Skills
Name of Provider: Training Site:
Expected Outcome:
Target Completion Date: Actual Completion Date:
Goal #3:
Training Program Description: Work Readiness Basic Skills
Name of Provider: Training Site:
Expected Outcome:
Target Completion Date: Actual Completion Date:
Additional Goal:
Training Program Description: Work Readiness Basic Skills
Name of Provider: Training Site:
Expected Outcome:
Target Completion Date:
Case Manager Comments:
SECTION 7 – PARTICIPANT AGREEMENT/SIGNATURE
I have assisted in the development of this plan and agree with it. I understand the established goals and will make every effort to follow through on achieving my goals within the agreed upon time frame. My plan can be updated periodically or modified to meet my needs. I understand that the development of this plan does not establish a right or guarantee to provide services. I further understand that a lack of commitment, participation, or follow-through on my part may result in my exit from the WIOA program.Participant Signature: Date:
Staff Signature: Date:
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