Digital ESL (DESL) Program Self-Assessment

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Section 1 to be completed at the time of enrolling in the program.
This is a self-assessment survey. Please answer the following questions regarding your current employment status and future career goals.
None of the information collected will be shared outside this agency. The USCIS status is collected to determine eligibility for other existing programs.

Today's date

YYYY

Referred by (if applicable)

Full Name *

Email address *

Phone number *

Date of birth *

YYYY

Date of US entry (month/year) *

County of residence *

USCIS status (upon US entry) *

Refugee

Asylum

Trafficked

Cuban entrant

Haitian entrant

Special Immigration Visa (SIV)

U-Status

US Citizen

Afghan OAR

Other

Current status if different than above.

1. Are you currently working? *

Yes full-time

Yes part-time

Yes self-employed/contractor

N/A

2. Do you receive benefits from your current job (medical insurance, paid vacation, paid holidays)? *

Yes

N/A

3. If you are not currently employed, do you plan to work in the next 12 months? *

Yes

N/A

4. On a scale from 0 to 10, 0 being the lowest and 10 the highest, how comfortable are you with the on-line job search and application process? *

List comfortable

Most comfortable

5. Are currently participating in any English language learning programs? *

Yes

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