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Participant Confidentiality Statement and Release Form
Commonwealth Corporation collects participant data to demonstrate that participants who complete training programs funded through the Workforce Competitiveness Trust Fund (WCIF) see an increase in wages and/or change in employment. This data provides a case for continuous funding for additional training programs.
I, , understand that the training program l am about to enter is paid for by the state of Massachusetts through the Workforce Competitiveness Trust Fund and FY21-23 ARPA appropriations. Commonwealth Corporation, which oversees the WCT for the state of Massachusetts, needs information about the training program and people attending training classes to be able to report to the state on how well the whole program is working and whether it is meeting its goals.
I understand that all information that I give to project staff about myself will be kept confidential. I also understand that project staff may ask my employer for information about my job and/or my pay and that this information will be kept confidential. other information about me, such as information from interviews, tests, reports from career counselors or other sources, will also be kept confidential and will only be used by WCIF and grantee staff to report on the whole program. Any information that can be connected to my name cannot be given out to anyone else without my permission.
l understand that, as part of the training program funded by the Workforce Competitiveness Trust Fund, Commonwealth Corporation will be collecting confidential information about me and my participation in the program. I have read and understood the above statement and give Commonwealth Corporation permission to collect and use my information and give permission for my employer to release job and/or wage information according to the statement above.
I understand that by giving my social security number on this form, I give Commonwealth Corporation permission to use this number to get information on the results of the Workforce Competitiveness Trust Fund. l understand that this information Will only be used to obtain state employment information to evaluate the Workforce Competitiveness Trust Fund projects and that my identity (name, address, etc.) will not be connected to the information obtained by the state.
Legal Signature Agreement
(Required)
By checking this box, I agree that my digital signature represents my legal signature for this document and the pages that follow.
By signing below, I acknowledge and agree to become a customer of the Mass Hire Pittsfield Career Center by way of enrollment in this training program.
By signing below, I give permission to have my photo taken and featured on the Mass Hire Berkshire Workforce Board social media page and/ or website.
Signature
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
HEALTHCARE/BEHAVIORAL HEALTH HUB CONTINUATION GRANT – PHASE 2 IMPLEMENTATION WCTF FY’21-FY’23 PARTICIPANT REGISTRATION FORM - REQUIRED
CONFIDENTIAL DATA: FOR OFFICIAL USE ONLY
Name
(Required)
First
Middle
Last
Date of Birth
Month
Day
Year
Social Security Number
(Required)
Email Address
(Required)
Phone Number
(Required)
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
What is your current employment status?
(Required)
Select one
Employed
Unemployed
If unemployed, how many weeks have you been unemployed during the last year?
(Required)
Please enter a number from
0
to
52
.
IF YOU ARE CURRENTLY EMPLOYED, PROVIDE INFORMATION ON CURRENT JOB. IF YOU ARE UNEMPLOYED, PLEASE SKIP TO THE NEXT SECTION.
Name of Employer
(Required)
Employer's City/Town
(Required)
Describe your employer's type of industry or what your company does.
(Required)
Job Title/Decsription
(Required)
Hourly Wage
(Required)
Average Hours Per Week
(Required)
FOR THE FOLLOWING QUESTIONS: IF YOU CHOOSE NOT TO ANSWER A QUESTION, PLEASE SELECT PREFER NOT TO DISCLOSE
I identify my gender as
(Required)
Select one
Male
Female
Non-binary
Prefer not to disclose
I identify my ethnicity as
(Required)
Select one
Hispanic or Latino (of any race)
Not Hispanic or Latino
Prefer not to disclose
I identify my race as (check all that apply)
(Required)
American Indian / Alaska Native
Asian
Black / African-American
Native Hawaiian / Pacific Islander
White
Some other race
Prefer not to disclose
Do you have a disability?
(Required)
Select one
Yes
No
Prefer not to disclose
Please complete all of the following questions:
Citizenship
(Required)
Select one
U.S. Citizen
Work Eligible Non-Citizen
Were you born in the United States?
(Required)
Select one
Yes
No
Veteran Status
(Required)
Select one
Gulf War Era Veteran
Other Veteran
None
Primary language spoken at home
(Required)
English
Other
If not English, what is your primary language?
(Required)
Unemployment Insurance Status
(Required)
Select one
U.I. Claimant
U.I. Exhaustee
Neither
Are you receiving any of the following public assistance benefits? (Check all that apply)
TAFDC (TRANSITIONAL AID TO FAMILIES)
EAEDC (EMERGENCY AID)
WIC NUTRITION PGM
SNAP (SUPPLEMENTAL NUTRITION ASST)
SSDI (SOCIAL SECURITY DISABILITY)
VETERAN’S CASH BENEFITS
SSI (SUPPLEMENTAL SECURITY INCOME)
MASSHEALTH
REFUGEE CASH ASSISTANCE
Do you receive a housing subsidy?
(Required)
Select one
Yes
No
If yes, what type of housing subsidy do you receive? (Check all that apply)
(Required)
MASSACHUSETTS RENTAL VOUCHER PGM (MRVP)
FEDERAL SECTION 8 VOUCHER PGM
NOT SURE OF SOURCE
SUBSIDIZED UNIT FROM STATE PUBLIC HOUSING
SUBSIDIZED UNIT FROM FEDERAL PUBLIC HOUSING
Do you receive a child care subsidy?
(Required)
Select one
Yes
No
If yes, what type of child care subsidy do you receive? (Check all that apply)
(Required)
EEC (DEPT OF EARLY EDUCATION AND CARE)
DCF (DEPT OF CHILDREN AND FAMILIES)
NOT SURE OF SOURCE
DTA (DEPT OF TRANSITIONAL ASSISTANCE)
HEAD START
Family Size - Include Yourself
Please enter a number greater than or equal to
1
.
Yearly Family Income
(Required)
Select one
$0 - $27,000
$27,001 - $36,500
$36,501 - $46,000
$46,001 - $55,500
$55,501 - $65,000
$65,001 - $74,500
$74,501 - $84,000
$84,001 - $93,500
$93,501 OR HIGHER
Select the highest level of schooling that you have completed
(Required)
Select one
LESS THAN HIGH SCHOOL DIPLOMA
HiSET / GED / HIGH SCHOOL EQUIVALENCY
HIGH SCHOOL DIPLOMA
SOME COLLEGE, NO DEGREE
ASSOCIATE’S DEGREE
BACHELOR’S DEGREE
MASTER’S DEGREE AND ABOVE
OTHER POSTSECONDARY TRAINING
Are you a single parent?
(Required)
Select one
Yes
No
Applicant Signature
(Required)
First Name
Last Name
Date
(Required)
MM slash DD slash YYYY