Building Better Opportunities – 2016-2020 /
Part One – Participant Details
Title: / Full name: / Date of Birth:
Participant ID: / Customer Ref No:
Delivery Organisation/Partner:
Date of Initial Assessment:
Part Two – Self Assessment
Please tell us about any recent jobs, work experience or volunteering activities the participant has been involved in: (this information helps us understand the participants work history and levels of experience)
Please tell us any qualifications or certificates that the participant has previously achieved: (we will ask for copies of certificates to be provided)
Please detail what the participant believes their best skills and qualities are: (this will help us understand the participant as a person)
Part Three – Participant Expectations and Goals
Please detail below what the participant expects to gain and would like to achieve from this programme (these can be job prospects, educational targets, emotional goals – please set both short term and long term goals)
Part Four – Barriers and Action Plan
Please discuss any potential barriers to achieving the participants expectations and goals from this programme (please take into account logistical, emotional and educational barriers as well as general barriers)
Describe below how this programme will be used to achieve the participants expectations and goals, and overcome the barriers as described above:
Summary of discussion:
Short-term action plan:
Long-term action plan:
Part Five – Other Information
Please detail any other relevant information that the participant feels may be useful to ensure they are supported through your programme:
Part Six – Interview and Survey
Below are some statements, please tick the box that best describes your personal feelings towards each statement, based on how you are feeling at the point of completing this form (please tick one per statement)
Statement / None of the time / Rarely / Some of the time / Often / All of the time
I know where to look to find a job / 1 / 2 / 3 / 4 / 5
I am feeling optimistic about the future / 1 / 2 / 3 / 4 / 5
I have been feeling confident / 1 / 2 / 3 / 4 / 5
I know how to adapt my CV to better support a specific job / 1 / 2 / 3 / 4 / 5
I have been able to make up my own mind about things / 1 / 2 / 3 / 4 / 5
I have been thinking clearly / 1 / 2 / 3 / 4 / 5
I know how to sell myself effectively in a job application / 1 / 2 / 3 / 4 / 5
I am able to work as part of a team / 1 / 2 / 3 / 4 / 5
I am able to solve problems / 1 / 2 / 3 / 4 / 5
I am able to use the phone to talk to people I do not know / 1 / 2 / 3 / 4 / 5
I am confident in delivering presentations / 1 / 2 / 3 / 4 / 5
I feel confident in my ability to find a job / 1 / 2 / 3 / 4 / 5
Part Seven – Declaration and Signatures
Please read the below information and declarations and confirm by signing that you agree and are happy with the following declarations:
- I know that the support I will be offered is funded by the European Social Fund and the Big Lottery Fund
- The information provided in the form is, to the best of my knowledge, accurate
- I give permission for my personal details to be shared and stored in a secure manner with the Big Lottery Fund and other authorised bodies
- I understand this information will be retained until at least 31st December 2026 for evaluation purposes. After that time, it will be destroyed in a secure manner
- I may be contacted at any time to discuss my involvement in the project
- I give permission for my details to be shared with other partners involved in the delivery of this project
Participant signature: / Date:
Delivery partner signature: / Date:
Page 1 of 4 | Initial Assessment and Entry Survey – Version 1