LIST OF STANDARDIZED PROGRAM FORMS

L a s t R e v. 9-1 4-17 LIST OF STANDARDIZED PROGRAM FORMS REQUIRED FORMS (based on participant needs): INDIVIDUAL EDUCATION & EMPLOYMENT PLAN CASE MANAGEMENT SESSIONS UPDATE JOB READINESS ASSESSMENT SUPPORT SERVICES VERIFICATION FORM EDUCATION STIPEND VERIFICATION FORM TRANSITIONAL EMPLOYMENT NOTIFICATION FOLLOW-UP SESSION UPDATE

L a s t R e v. 8-1 - 17 E-mail (voluntary): Primary Phone (voluntary): Preferred Contact method: INDIVIDUAL EDUCATION AND EMPLOYMENT PLAN LAST FIRST MIDDLE Alternate Phone (voluntary): Best time to call: BASIC NEEDS & SKILLS ASSSSMENT SUMMARY (for completion by Career Coach for action planning discussion with participant) EDUCATION & EMPLOYMENT: barriers to education and employment (check those that apply): Limited English Lack of basic skills/ low test scores No high school diploma/ged Computer Basics No or limited Work Experience Lack of transferable skills Skill upgrade needed Other barriers: JOB READINESS: No Driver s License/ID No Resume People Skills Personal Accountability Appearance/Work Presentation Other challenges: SUPPORT SERVICES NEEDED to address barriers faced (if none needed, please indicate; update as necessary) Potential support services that could be provided by LARCA 2.0 Service Provider or 3 rd party referral: Type of Service Provider and/or Program Duration CAREER GOALS (PARTICIPANT S EDUCATION OR EMPLOYMENT OBJECTIVE) What are your short term career goals? (within the next year) What are your long term career goals? (within next 2 to 5 yrs.) Planned Attainment Planned Attainment OCCUPATIONAL AREAS AND JOB TITLES FOR CONSIDERATION:

JOB READINESS WORKSHOPS & SERVICES TOPIC MY ACTION PLAN (steps to help you achieve your career education or employment goals) PLANNED COMPLETION DATE Jobs Search Skills Resume Writing Interviewing Skills Job Research & Prep Computer basics Customer Service Other: EDUCATION AND VOCATIONAL TRAINING Objective: (e.g. skills upgrade, basic skills remediation, industry certificate, etc.) Provider & Course or Type of training TOPIC Work Etiquette Soft skills/people s Skills Stress Management Personal Accountability Money Management Other: Other: PLANNED COMPLETION DATE Projected Start Date Projected End Date EDUCATION AND TRAINING STIPENDS (Total two at $500 each; at 50% and at conclusion of participant s education goals) Vocational Training and Education Objective (list course or program) Target Goal Amount: Milestone #1 $500 Milestone #2 $500 Comments: PAID WORK EXPERIENCE (TRANSITIONAL EMPLOYMENT up to 400 hours for participants with no or limited work history) Employer: Total Hours: Start End Hourly Rate: Position: Comments : EMPLOYMENT Desired employment /Job title: Desired Hours Per Week: I will work with my career coach to complete the following: Desired Minimum Hourly Wage: Job Readiness Workshops Required Job Search Prep Research labor market information Upload resume to CalJobs Develop template for cover letters, references, etc. Other: I will work with my career coach to develop specific employment strategies: Research job leads, employers, hiring events Attend job fairs and recruitments Update/Customize resume to specific job openings Report employment information once a job is secured Pursue employment leads provided by my coach Other: Utilize post-exit follow-up services for retention support LARCA 2.0 Service Provider:

L a s t R e v. 8-1 - 17 CASE MANAGEMENT SESSIONS UPDATE LARCA 2.0 Service Provider: The individual is participating in the following service track: Month: Only Education/Training Education/Training AND Employment Only Employment Participant s IEP Action Item: Case Management Session Session #: Current Status Job Readiness Workshop(s): Job Readiness Assessment (Readiness Services & Workshops) Education Objective: Vocational Training Objective: Education & Training Stipend Milestone #1 Education & Training Stipend Milestone #2 Paid Work Experience (Transitional Employment) Job Readiness Assessment (Transitional Employment) (half way point) Job Readiness Assessment (Transitional Employment) (end) Employment strategies: Job Placement Addressing Personal Barriers: Addressing Personal Barriers: Other: Accomplishments/Challenges: Next step(s): Staff Signature:

LARCA 2.0 Service Provider: L O S ANGELES RE CONNECT IONS CAREER ACA D E MY (LARCA ) 2.0 JOB READINESS ASSESSMENT L a s t R e v. 8-1 - 17 Participant/Employee: Claim #: Check one: I n i t i a l (jo b r e a d i n e s s s e r v i c e s ) W o r k E x p e r i e n c e ( h a l f p o i n t ) W o r k E x p e r i e n c e ( e n d p o i n t ) Review Reviewers: P E R S ONA L REA DI NESS: ( t o b e c o m p l e t e d b y c a r e e r c o a c h o r c a s e m a n a g e r ) Stable Housing: Housing situation is supportive of work. Aware of resources should there be changes. Stable Childcare: Child care arrangements are supportive of work. Stable Health: Current health status should not impede employment or performance. Stable Legal Status: Has right to work documentation necessary for employment. No warrants out for arrest. No near term court dates. Transportation: can readily get to and from work via public transit or car from current home. Comments: W O RK EXPERIENCE P R O G RA M ( T r a n s i t i o n a l E m p l o y m e n t ) N/A Hire Job Title: Employer: Review Reviewers: JOB READINESS STANDARDS: Please score the participant using the following 1 to 5 scale: [1] Major Improvement Needed [2] Some Improvement Needed [3] Meets Expectations [4] Often Exceeds Expectations [5] Consistently Exceeds Expectations ATTENDANCE & PUNCTUALITY Arrives on a timely manner. Adheres to expectations for attendance. Notifying in case of tardiness or absence. PERFORMANCE & RESPONSIBILITY Responds favorably to assignments and instructions. Completes tasks accurately and on time. Demonstrates dependability and reliability. Acts with integrity and honesty. COMMUNICATION & ATTITUDE Communicating effectively. Uses language appropriate for work environment. Interacts appropriately with his/her peers and/or with staff and supervisors. Exhibits a positive attitude. Behaves as if s/he is in a work environment. APPEARANCE Dresses appropriately for meetings. Appropriate for work position and duties. The maximum score is 50. A score of less than 30 indicates the participant is not job ready. A score of 40 or greater, participant is encouraged to seek out mainstream employment. TOTAL

School/ Employer: REQUEST FOR SUPPORT SERVICES AND VERIFICATION FORM Participant Request for Support Services: The participant requested the following support services necessary to engage in LARCA 2.0 program activities. The cost of the service is reasonable and allowable. It is necessary to use LARCA 2.0 funds to pay for the support services. Other non-larca 2.0 resources were unavailable. SUPPORT SERVICES EXPENDITURES For the period Beginning: Ending: TYPE OF SUPPORT SERVICE: AMOUNT TRACKING DETAILS Tap Card $ Tap Card No: Tokens $ No. of bags: Gas Card $ Card No: Reimbursement $ For: Clothing/Uniform $ Item: Needs-based payment: S For: Child care $ Provider/Type: Other $ Specify item: Other $ Specify item: Purpose/Comments: Payable to: LARCA 2.0 Service Provider Agency: Staff signature: Manager signature: VERIFICATION OF SUPPORT SERVICES RECEIVED I received the Support Service(s) listed above. Participant signature:

L O S ANGELES RE CONNECT IONS CAREER ACA D E MY (LARCA ) 2.0 L a s t R e v. 8-1 - 17 EDUCATION & VOCATIONAL TRAINING STIPEND VERIFICATION FORM EDUCATION & VOCATIONAL TRAINING STIPENDS Eligible participants may receive, one-time only, stipends up to $1,000 pursuant to the completion of education and training milestones outlined in their Individual Education and Employment Plan. 1. Education Milestone: a $500 stipend upon successful completion of education services including, but are not limited to, basic skills remediation training, computer literary, ESL/VESL, literacy and numeracy skills development. 2. Vocational Training Milestone: a $500 stipend upon successful completion of vocational training including, but are not limited to, occupational skills training, industry-standard certification, apprenticeships, entrepreneurial training, on-the-job training, skills upgrading and retraining, customized training, postsecondary education. DETAILS: Education and Vocational Training Objective Amount (list course or training program) MILESTONE #1 $500 Date Participant Met Goal MILESTONE #2 $500 COMMENTS: Payable to: LARCA 2.0 SERVICE PROVIDER AUTHORIZATION Agency: Staff signature: Manager signature: I received the Education Stipend(s) listed above. VERIFICATION OF EDUCATION STIPENDS RECEIVED Participant signature:

L O S ANGELES RE CONNECT IONS C A REER ACA D E MY (LARCA ) 2.0 TRANSITIONAL EMPLOYMENT NOTIFICATION Last Rev. 8-1-17 Address: LARCA 2.0 Service Provider: Employer of Record: For the position of: This is a temporary part/full-time position for up to 400 hours of transitional employment at minimum at the City s minimum hourly wage, dependent upon your performance and funding. This position is considered to be part of a training program, the Los Angeles Reconnections Career Academy 2.0 Program, and meant to provide you with paid work experience that you will be able to include on your resume. As such, this part/full-time employment is at will and permits the company, worksite, or the employee to terminate the employment relationship at any time for any reason. City of Los Angeles Minimum Wage Schedule July 1 26+ Workers 25 or fewer 2017 $12.00 $10.50 2018 $13.25 $12.00 2019 $14.25 $13.25 2020 $15.00 $14.25 As is customary, this opportunity is conditioned upon the successful completion of the Employer of Record s pre-employment screening process, which may consist of completed intake/eligibility paperwork, a fingerprint/background check and in some instances, a drug test. Therefore, should any information regarding the pre-employment screening, be returned unacceptable or inconsistent to what the Employer of Record might have been previously informed, the Employer of Record may terminate the employment relationship immediately and you will be returned to the job assistance center that referred you for further action. If you have any questions regarding the contents of this letter, please feel free to contact me: Sincerely, Agency Rep: Agency Rep Signature: Accepted: Applicant Signature

L a s t R e v. 9-1 4-17 FOLLOW-UP SESSION UPDATE LARCA 2.0 Service Provider: Month: Follow-up Session Session #: Employer: Employer Address: Job Title: Start What is the participant s status of employment? FOLLOW-UP QUESTIONS Hourly Wage: Employed (full-time) Employed (part-time) Not Employed If employed, has there been any changes with the position (pay increase, change in title, promotion, etc.)? If Yes, please explain: If NOT Employed, please explain reason: Please detail additional job placement assistance to be provided: Is there is a need for support services or other assistance? If answered Yes, please explain: Other Accomplishments/Challenges: Next step(s): Staff Signature: