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Literacy Intake Form
Literacy Intake Form
admin
2021-03-08T20:31:30+00:00
Literacy Intake Form
Step 1 of 4
25%
Participant Details
Name
*
First
Last
Preferred Name
First
Last
Social Insurance Number
I identify as (Select only one)
*
Man
Woman
Trans
Prefer not to disclose
Other
Please Specify
*
Status in Canada
*
Canadian Citizen
Permanent Resident
Other
Please Specify
*
Preferred Language
*
English
French
Other
Immigrated to Canada?
*
Yes
No
Not Applicable
Prefer not to disclose
Preferred Communication
*
Phone
Email
Hard Copy
Marital Status
*
Single
Married (or equivalent)
Undisclosed
Please complete if you wish to self-identify as a member of a designated group(s). Your response to this question is entirely voluntary and will not affect your eligibility. This information will be used by the Governments of Ontario and Canada for policy analysis and statistical purposes related to employment programs and services. (You may select more than one (1) option:)
Newcomer
Racialized Person
Deaf/Blind
Person with Disability
Inuit
Métis
First Nations
Deaf
Francophone
Primary Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Alternate Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Primary Phone Number
*
Alternate Phone Number
Email
*
Education
Indicate your Highest Level of Education/Qualification:
*
Grade 0 - 8
Grade 9
Grade 10
Grade 11
Grade 12 (or equivalent)
OAC
Certificate of Apprenticeship
Journey Person
Certificate/Diploma
Applied Degree
Associate Degree
Bachelor's Degree
Post Graduate
Institution of Highest Level of Education
Program Description
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
Type
Full-Time
Part-Time
Country of Institution
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Additional Education
Some Apprenticeship
Some College
Some University
Institution of Additional Education
Program Description
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
Type
Full-Time
Part-Time
Country of Institution
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Employment List your most recent work experience.
Employment Type
Paid
Self Employed
Unpaid
Volunteer
Name of Employer
Job Title/Duties
Employment Start Date
Date Format: MM slash DD slash YYYY
Employment End Date (If Applicable)
Date Format: MM slash DD slash YYYY
Country of Enployment
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Pay Period
Hourly
Weekly
Bi-Weekly
Monthly
Yearly
Wage Amount ($)
Employment Hour Per Week
Reasons for Leaving (If Applicable)
Client Self-Assessment
How long do you think you will spend in the program (weeks)?
*
1-2
2-3
3-5
5+
On average, how many hours a week can you devote to your leaning in class?
*
1-5 Hours
5-10 Hours
10-20 Hours
20+ Hours
On average, how many hours a week can you devote to your leaning on your own time?
*
1-5 Hours
5-10 Hours
10-20 Hours
20+ Hours
Notice of Collection and Consent
Your organization delivers Literacy and Basic Skills under an agreement with the Ministry of Labour, Training and Skills Development (Ministry) and is required to make its records available to the Ministry for inspection, investigation or audit. Your organization is also required to report to the Ministry on: • the service it tailors and provides you; • your employment progress and outcome; and • your satisfaction with the services you receive. The Ministry will also collect relevant personal information about you from the Government of Canada (Canada) if necessary. The purpose of this information is to determine your eligibility for Employment Insurance benefits, the nature and level of Employment Insurance benefits, and to monitor, assess and evaluate the effectiveness of Literacy and Basic Skills. Depending on the type of service or support you receive and any incentives available to your employer to hire you, your organization or the Ministry may also collect personal information about you from your employer. The Ministry may use contractors and auditors to administer and finance Literacy and Basic Skills. Administration includes: • Assessing the performance of your organization – its effectiveness, efficiency and customer service results; monitoring, inspecting, investigating, auditing and enforcing your organization’s compliance with its agreement with the Ministry. • Planning, evaluating and monitoring Literacy and Basic Skills – this includes conducting surveys, and conducting policy and statistical analysis and research related to all aspects of Literacy and Basic Skills. You may be contacted to request your voluntary participation in surveys. • Promoting Literacy and Basic Skills – you may be contacted to request your voluntary participation in public relations campaigns related to Literacy and Basic Skills. If you are a client of, or applying to, the Ontario Disability Support Program or Ontario Works, the Ministry will provide your personal information to the Ministry of Children, Community and Social Services (MCCSS) for the purposes of administering employment services and managing the participation of MCCSS clients in employment support programs under the Ontario Works Act, 1997, and the Ontario Disability Support Program Act, 1997. Literacy and Basic Skills is funded by the Ministry, in part with funds provided by Canada under Part II of the Employment Insurance Act. When funds are provided by Canada, the Ministry is required to provide information to Canada to help monitor and assess the Employment Insurance Program, as required under s.3 of the Employment Insurance Act. Under the Labour Market Development Agreement between Canada and Ontario (LMDA) and the Workforce Development Agreement between Canada and Ontario (WDA), the Ministry is required to collect your social insurance number. The Ministry collects your personal information pursuant to the LMDA and WDA, ss. 3 and 63 of the Employment Insurance Act, S.C. 1996, C.23 as amended, and s.76.29 of the Employment Insurance Regulations, SOR/96-332. The Ministry will collect personal information from clients who identify as Ontario Disability Support Program or Ontario Works recipients and disclose your personal information to MCCSS in accordance with the s.71 of the Ontario Works Act, 1997, and s.53 of the Ontario Disability Support Program Act, 1997. For more information about the collection and use of your personal information to administer and finance Literacy and Basic Skills, you can contact the Manager, Employment Ontario Call Centre, in writing at the Ministry of Labour, Training and Skills Development, 33 Bloor Street East, 2nd Floor, Toronto, Ontario M7A 2S3 or by phone at 1-800-387-5656. For the hearing impaired, TTY is available at 1-866-533-6339.
Participant's Name
*
First
Last
Participant Signature
*
Date
*
Date Format: MM slash DD slash YYYY
Parent/Guardian's Name
*
First
Last
Participant Signature (if applicant is under 16 years old)
Date
*
Date Format: MM slash DD slash YYYY
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