KPACE Referral Screening Tool

This assessment tool is intended to assist in the screening of potential applicants for the KPACE program. Please fill out as completely as possible and add comments when applicable. Use the numerical values for each question to determine a total at the end of the assessment. This tool will be used to determine eligibility for the KPACE program.

Date: Referring Agency/Staff email/phone:

Client Name:

Best way to reach client? (email, cell phone, home phone)Primary: Secondary:Please list any agencies that are currently assisting the client: (Example: DHS, Young Parents Network, 6th

Judicial District, etc.)

Circle Cohort Interest: Welding Nurse Aide Business Computing

Eligibility Criteria Questions: YES NOAre you at least 17 years old? Are you a resident of Benton, Cedar, Iowa, Jones, Johnson, Linn or Washington county?Are you currently employed?

Instructions: Complete this form for entry into the KPACE program. Select one level in each of the areas below by circling the number next to the appropriate level. A. Income

0) Income unknown1) No income2) Inadequate income 3) Can meet basic needs with subsidy4) Can meet basic needs but finances not well managed5) Income is sufficient, well managed

Comments:

B. Employment0) Job status unknown1) No job2) Temporary, part-time or seasonal employment3) Employed full-time; inadequate pay with few or no benefits4) Employed full-time with adequate pay and benefits5) Maintains permanent employment with adequate pay and benefits

Comments:

1. Adapted from Project ARIBBA Individual Service Strategy2. Adapted from Rural Arizona HMIS Self-Sufficiency Matrix

C. Shelter0) Housing status unknown1) Homeless or threatened with eviction2) In transitional, temporary or substandard housing; current rent/mortgage is unaffordable3) In stable housing that is safe but only marginally adequate4) Household is safe, adequate, subsidized housing5) Household is safe, adequate, unsubsidized housing

Comments:

D. Food0) Unknown1) No food or means to prepare it. Relies on sources of free or low-cost food2) Household is on food stamps3) Can meet basic food needs but requires occasional assistance4) Can meet basic food needs without assistance5) Can choose to purchase any food household desires

Comments:

E. Childcare0) Unknown1) Needs childcare, but none is available/accessible or child is not eligible2) Childcare is unreliable or unaffordable3) Affordable subsidized childcare is available but limited4) Reliable, affordable childcare is available; no need for subsidies5) Able to select quality childcare of choice or has no children

Comments:

F. Education0) Education status unknown1) Literacy problems and/or no high school diploma/GED are serious barriers to employment2) Enrolled in literacy and/or GED program3) Has high school diploma/GED4) Needs additional education/training to improve employment situation5) Has completed education/training needed to become employable

Comments:

G. Transportation0) Transportation status unknown1) No access to transportation, public or private2) Transportation is available but unreliable, unpredictable, unaffordable3) Transportation is available and reliable but limited and/or inconvenient4) Transportation is generally accessible to meet basic travel needs5) Transportation is readily available and affordable

Comments:

1. Adapted from Project ARIBBA Individual Service Strategy2. Adapted from Rural Arizona HMIS Self-Sufficiency Matrix

H. Behavioral Considerations/Motivation0) Unknown1) Dependent on others for information and assistance; poor follow-through2) Seeks out information and assistance but inconsistent follow-through3) Calls for help when needed; adequate level of motivation4) Willingness to learn and utilize resources; consistent follow-through and motivation5) Highly motivated; independent and committed to improvement

Comments:

I. Mental Health0) Unknown1) Has a diagnosed mental health issue that would absolutely interefere with training. Class

attendence and completing assigned work would be a significant challenge. 2) Has a diagnosed mental health issue that could interfere with training. Individual is not

accessing or receiving all needed mental health services. Class attendance and completing assigned work could be an issue.

3) May have a mental health issue but has not been diagnosed. Some concern that the individual’s presenting issues could interfere with training. Class attendance and completing assigned work would not likely be an issue.

4) Has a diagnosed mental health issue, however, is well managed and would not interfere with training.

5) No mental health issues that would interfere with training. Comments:

Please add up the numerical value of each score indicated and enter score here: ____________(If any category received a zero score due to unknown status, please proceed with referral. The KPACE Pathway Navigator will follow up with the client to review appropriateness for the program.)

Based on the score indicated above, please use the scoring matrix to determine the client’s eligibility for the KPACE program. Please fax the completed assessment tool to Mialisa Wright at 319-398-1049 or scan and send to mialisa.wright@kirkwood.edu. Confirmation of receipt will be sent within 5 days.

1. Adapted from Project ARIBBA Individual Service Strategy2. Adapted from Rural Arizona HMIS Self-Sufficiency Matrix

Scoring MatrixScore: 35-45

Very strong candidate. Please refer to KPACE program by faxing or scanning this document

Fax:319-398-1049 or mialisa.wright@kirkwood.edu

Attn: Mialisa Wright

Score: 23-34Good Candidate for program.

Please contact Bethany Parker to discuss potential barriers and

extenuating circumstancesmialisa.wright@kirkwood.edu

or 319-784-1518.

Score: 12-23Questionable candidate at this

time.May need extensive support

services in order to succeed in this program. Please contact Bethany Parker if you feel this

candidate has potential to succeed that is not reflected in

their score.

Score: 1-11Do not refer to program.

This client has too many financial and/or personal barriers to

succeed in this program at this time.

Re-assess eligibility in 6 months.