NEW JERSEY INTAKE AND INITIAL ASSESSMENT FORM Today’s Date

______/______/_____
UNDERLINED SECTIONS MUST BE COMPLETED. PLEASE COMPLETE ADDITIONAL FORMS IF INDICATED..
09 16 2024

SSN# 143640051 Date of Birth _______/_______/_______

07 20 1964 MM/DD/YYYY Gender Female Male
Last Name First Name Middle Initial
Boyd Tanya M

Street City State ZIP Code County

18 Stanger Ct Clayton NJ 08312 Glouchester

Phone #: Email: Contact Preference Postal E-mail

609-670-2990 [email protected] Primary Phone Alt. Phone
Ethnic Heritage Hispanic or Latino Not Hispanic or Latino Marital and Family Status (choose all that apply)
I choose not to disclose married divorced unmarried
Race Asian Alaskan/American Indian White
Household one-parent two-parent
Black/African American Hawaiian/Pacific Islander not a family member(single) other (dependent, child)
I choose not to disclose optional: pregnant
School Status
In-school: HS/secondary or Less alternative HS/Post-secondary Employment Status (choose one)
Not attending school: HS dropout HS grad/equivalent employed not employed
16 or younger and did not attend last school year quarter employed but received notice of termination
not employed and not seeking work
Education Level (Choose highest level only) If employed are you working (choose one)
no grade Yrs completed, (1-11) no diploma full-time part-time
12th grade, no diploma 12th grade, HS grad seasonal/temporary self-employed
HS equivalency disabled w/ Cert. IEP If not employed and homemaker:
Receiving support from spouse/former spouse
Post-secondary/Vocational/Associate/High School Plus Not receiving support from spouse/former spouse
Post-secondary no degree 1 year 2 years 3 years
Vocational Certificate 1 year 2 years 3 years US Citizen
Associate Degree 1 year 2 years 3 years Yes No Permanent Resident or Exp.Date: ________
Other Degree BA/BS Master’s PhD Alien Reg.# (if applicable): ___________

Individual with Disability Yes No Choose not to disclose [If Yes, please ask staff for Form D, which is kept
confidential, and specify your type of disability: hearing; vision; mental; mobility; cognitive/I/DD; learning; chronic health]

Migrant Seasonal Farmworker

Yes No If Yes, choose one: migrant seasonal farmworker migrant farmworker migrant food process worker
dependent of migrant seasonal farmworker Farmwork Type: food processing production and services
Selective Service (Males born on or after 1/1/1960 only) Native Language English other - specify:
Yes No
Selective Service # _________________________ Military Service Yes - branch: _____________ No
……………………..If Yes, use DVOP Checklist
Housing (choose one) campaign veteran National Guard Reserve active duty
foster child aged out of foster care transitioning vet discharged retirement other eligible
homeless runaway active service - from ___________ to ___________
own home rent Service Disability
choose not to disclose disabled not disabled special disabled
none of the above apply Receiving Veteran’s benefits or assistance? Yes No
If Yes, specify: _____________________________
Offender Status - Have you been convicted of a
criminal offense? Yes No Military Spouse - Are you a:
spouse of active duty service member
Do you believe you have any barriers to employment,
widow of a service member spouse of a disabled veteran
including customs, practices or beliefs, not described on
this form, which you wish to disclose? Yes No If you are the spouse of an active duty service member, has your income been
If Yes, please provide this information on Form D. affected by your spouse’s deployment?
Yes No
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 Employment Preferences
Work Week full-time part-time both not seeking employment at this time
Duration regular (150 Days+) temporary (150 days or less) both
Minimum Salary $____________
30-34 Per ________
hr Date Available to Work _____/____/_________
09 16 2024

Shift Preference Willing to work any shift? Yes No If No, which shift(s): 1st 2nd 3rd Split Rotating
Employment Objective __________________________________________ Desired Job Title(s) 1)__________________________
Patient Access Manager

2)____________________________ 3) ______________________________4)_______________________5)____________________
Patient Access Supervisor Office Practice Manager

Desired Employer(s) 1) _______________________________ 2) ______________________________3)_______________________

Acceptable Job Locations (check one): 5 10 25 50 100 miles from ZIP Code ___________

Work History (current/last employer) Job Title _________________________________

Patient Access Manager Employer ___________________________________
Jefferson East Region

Street __________________________________
435 Hurfville cross keys rd City ____________________
Turnersville State _____________________
NJ

Start date _____/_____/________

02 06 1992 End date _____/_____/________
07 18 2024 Wage $____________
38.00 per_______________
hr

Reason for leaving lack of work/layoff fired medical/health quit retired strike still employed
other (specify) _______________________________________________________________________
position was eliminated

Job duties _______________________________________________________________________________________________________________

Daily Operations of Patint Access Emergency room registratrion, Payroll, Staff schedue, Daily work queue reports and audits, performanxce evaluation, disciplinary correctives , conducted interviews, onboarding training

________________________________________________________________________________________________________________________
____________________________________________________________________If you wish to provide additional work history, inform staff person.
Additional Skills ________________________________________________________________________________________________________
Professional Associations ________________________________________________________________________________________________
Certificate/Special Licenses
Certificate/License __________________________________________________________ Issued by __________________________________
Date issued ____/_____/________ State _________ Country ______________________________
Education/course of study ____________________________________________________________ Degree ______________________________
School __________________________________________________________ State _________ Country ______________________________
Driver License
License No Yes State ___________________ Endorsements
Type CDL-A CDL-B CDL-C Auto Moped passenger transport motorcycle
Transportation I own a vehicle I have insurance hazardous materials tank vehicle school bus
I have access to: vehicle motorcycle bus/ rail none other doubles/triples tank hazards air brakes

I attest that the information provided is true and accurate. Any misrepresentation may be grounds for termination from program(s).
I also understand that being eligible for services and/or training does not necessarily entitle me to service/training.
Applicant Signature_________________________________ Date______ Parent/Guardian*__________________________ Date: _____
Tanya Boyd 09162024

STAFF USE ONLY

TANF Assistance start date ________ Income Status
WIOA Adult WIOA Dislocated Worker
SNAP Case # ____________ 100% LLSIL 70%LLSIL Not Disclosed
WDP Grant (Specify: _______________)
GA Local Priority (Specify): _______________
National Dislocated Worker Grant
CAVP
Barriers to Employment ELL/Lower Level Literacy Substantial Cultural Barriers WDB (County) Code
Youth In/Aged out of Foster Care Low-Income Individual Displaced Homemaker Disability _________
Indian/Alaska native/Native Hawaiian Homeless Individual Long-Term Unemployed Ex-Offender
Within 2yrs of TANF exhaustion Eligible MSFW Single Parent Older Individual
WIOA Youth ISY WIOA Youth OSY Low-Income Additional Info Underemployed Not in Labor Force AOSOS ID#:
High Poverty Area 5% Limitation Interested in Nontraditional Employment _______________
OSY Foster Youth Dropout Homeless Not Attended Last Q Referral Source
Offender Low Income AND Basic Skills Deficient Pregnant/parenting DVRS LWD UI Public Assistance Agency
Disability Low Income AND youth who Requires Add’l Assistance CBO/FBO Self Other Local Area CSBG
Employer HUD Adult Education Library
ISY Low-Income AND BSD English Language Learner Probation Parole Public Education Relative/Friend
Offender Homeless Foster Youth Pregnant/parenting Re-entry/Second Chance Displaced Homemaker Program
Disability Youth who Requires Add’l Assistance Family Success Center MSFW Grantee
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