Pre-Apprentice Intake Form (AM) P-ZApprenticeship Programs at SUNY

Pre-Apprentice Intake Form (AM)

P-Z

Apprenticeship Programs at SUNY

This form is to provide SUNY with details on participants that will be served by Apprenticeship Programs at SUNY. This form must be completed in its entirety as an incomplete form cannot be saved and returned to at a later time. Please forward questions or request for additional information to: apprenticeship@suny.edu.

SUNY FOLLOWS OCCUPATION TRADE TITLES AMONG ADVANCED MANUFACTURING, HEALTH CARE/HUMAN SERVICES AND OTHER (EXCLUDING CONSTRUCTION) SECTORS. PLEASE ENSURE YOU ARE COMPLETING THE CORRECT FORM THAT ALIGNS WITH THE SECTOR AND TRADE TITLE.

Enter Today's Date as YYYYMMDD*

Please note, all dates will be entered as YYYYMMDD with no "/" or "-" between the numbers.

Agreement #*

Select agreement number in the dropdown.

There is a search option available to locate appropriate agreement number

Select

Participant Last Name*

Do not use all capital letters.

Participant First Name*

Do not use all capital letters.

Street*

City*

Zip Code*

Enter the basic five-digit code only. Do not use the zip+4 format. (i.e. 12077 or 13501)

In What State Does Participant Live?*

Select

Participant Social Security Number*

The purpose of this disclosure is to assist SUNY and its Partner Agencies in obtaining and reporting required information, including wage and employment data, to track the long-term success of this program. Your personal information is kept confidential and secure.

Although you cannot be denied service for failure to provide your Social Security Number, we strongly encourage you to do so in order to enable the project to quantify specific employment-related outcomes.

Enter number in the following format with no dashes 333224444. If you elect not to submit your social security number please enter 999999999.

Select Region Where Participant Lives or Will Attend College (Including Participants who Live Out of State)*

If participant does not live in NYS select region where the college is located.

Western NY

Finger Lakes

Southern Tier

Central NY

Mohawk Valley

Capital Region

Mid - Hudson

New York City

Long Island

North Country

Is Participant a U.S. Citizen?*

1-Yes

0-No

1

0

Participant Phone Number*

Enter phone number in the following format 555-555-5555. If number not available please enter N/A.

Participant Email Address*

If no email address please enter N/A.

Participant's Date of Birth*

Enter as YYYYMMDD.

Is the Participant Hispanic/Latino?*

1-Yes 0-No 9-Participant Did Not Self Identify

1

0

9

Is the Participant American Indian/Alaska Native?*

1-Yes 0-No 9-Participant Did Not Self Identify

1

0

9

Is the Participant Asian?*

1-Yes 0-No 9-Participant Did Not Self Identify

1

0

9

Is the Participant Black/African American?*

1-Yes 0-No 9-Participant Did Not Self Identify

1

0

9

Is the Participant Native Hawaiian/Other Pacific Islander?*

1-Yes 0-No 9-Participant Did Not Self Identify

1

0

9

Is the Participant White?*

1-Yes 0-No 9-Participant Did Not Self Identify

1

0

9

Please Select the Sex of the Participant*

1-Male

2-Female

9- If Participant Did Not Self-Identify or Identifies as "X" Other Gender Identity.

1

2

9

Is the Participant a Veteran or an Active Service Member?*

Record "1" if the participant is a person who served on active duty in the armed forces and who was discharged or released from such service under conditions other than dishonorable. A person who is on active duty is in the military full time. They work for the military full time, may live on a military base, and can be deployed at any time.

An individual in the Reserve or National Guard is not full time active duty military personnel, although they can be deployed at any time should the need arise.

Record "0" if the participant does not meet the condition described above.

Record "9" if participant does not disclose veteran status.

1

0

9

Veteran Status

Record "1" if participant served in the active U.S. military, naval, or air service for 180 or less days and was discharged or released from such service under conditions other than dishonorable.

Record "2" if participant (a) served on active duty for more than 180 days and was discharged or released with other than a dishonorable discharge; (b) was discharged or released because of a service connected disability; or (c) was a member of a reserve component under an order to active duty pursuant to section 167(a), (d), or (g), 673 (a) of Title 10, U.S.C., served on active duty during a period of war or in a campaign or expedition for which a campaign badge is authorized and was discharged or released from such duty with other than a dishonorable discharge.

Record "3" if the participant is the (a) spouse of person who died on active duty or of a service connected disability; (b) spouse of member of Armed Forces serving on active duty is listed, in one or more of the following categories for more than 90 days: (i) missing in action; (ii) captured in the line of duty by a hostile force; or (iii) forcibly detained or interned in the line of duty by a foreign government or power; or (c) spouse of any person who has a total disability permanent in nature resulting from a service connected disability or the spouse of a veteran who died while a disability so evaluated was in existence.

Record "0" if the participant does not meet any one of the conditions described above. Leave “blank” if the data is not available.

1

2

3

0

In Which Military Branch is(did) the Participant Serve?

Army

Marine Corps

Navy

Air Force

Space Force

Coast Guard

National Guard

Military Service Dates

If participant served or is currently serving in the military, indicate service dates

Start Date: YYYYMMDD

End Date: YYYYMMDD

Does Participant Have a Military Service Related Disability?

A service-connect disability is an injury or illness that was directly caused by military service, sustained while in the military (both on-duty and off-duty injuries may be service connected, i.e., knee injury playing basketball off duty), was aggravated by military service, or was caused by conditions that are themselves service-connected.

1 - Yes has a service related disability

0 - No does not have a service related disability

Select or enter value

Select the Highest Educational Level or Credential the Participant had Completed at Program Entry?*

1-Attained secondary school diploma

2-Attained secondary school equivalency (GED/TASC)

3-Participant with a disability received a certificate of attendance/completion as a result of successfully completing an Individualized Education Program (IEP)

4-Completed one of more years of post-secondary education

5-Attained a post-secondary technical or vocational certificate (non-degree)

6-Attained an Associate degree

7-Attained a Bachelor's degree

8-Attained a degree beyond a Bachelor's degree

0-No higher education completed

1

2

3

4

5

6

7

8

0

Select the Highest School Grade the Participant Completed at Program Entry?*

0-No Grades completed

1-1st Grade

2-2nd Grade

3-3rd Grade

4-4th Grade

5-5th Grade

6-6th Grade

7-7th Grade

8-8th Grade

9-9th Grade

10-10th Grade

11-11th Grade

12-12th Grade

Leave blank if highest school grade completed is not available.

0

1

2

3

4

5

6

7

8

9

10

11

12

Select the College Providing the Pre-Apprentice Training.*

Select

Type of Pre-Apprenticeship Training*

Anyone may register for a community-based training to gain skills needed to enter an apprenticeship occupation.

Incumbent worker pre-apprenticeship supports the selection of Registered Apprentices from a registered sponsor/signatory’s current employment base.

Incumbent-Based Training

Community-Based Training

What is the Participant's Employment Status at Program Entry?*

Employed

Not Employed

Not in Labor Market

Employed Received Notice of Termination

Migrant or Seasonal Worker

Name of Employer

If the employer name is not located in the dropdown list, ensure the trade the participant is pursuing is within this SUNY sector.

Click here for a comprehensive Occupation by Sector Chart. Please email apprenticeship@suny.edu if an employer name needs to be added.

Select

Most Recent/Current Employer*

If participants is currently employed but not attending training based on employer recommendation, enter employer name. Enter full/legal name.

If participant was never employed or employer name was entered above, enter "N/A".

Employer Address*

If listed employer in either of above two questions, provide address of employer.

If participant was never employed, enter "N/A".

Participant Job Title*

Enter job title for position at employer listed above.

If participant was never employed, enter "N/A".

Participant Job Duties*

Enter job duties of participant for position at employer listed above in 50 words or less.

If participant was never employed, enter "N/A".

Participant Wage*

Enter wage of participant at employer listed above. May be entered as hourly or annual.

If participant was never employed enter "N/A".

Employment Start Date*

Enter as YYYYMMDD or "N/A"

Full- Time or Part-Time Employment*

If employer was listed, is job full-time or part-time?

1- Full-Time (>30 hours/week)

2- Part-Time (<30 hours week)

0- Never employed or no longer employed

Select or enter value

Is Employment Permanent/Year-Round or Seasonal?

1 - Yes

0 - No

1

0

Reason for Leaving Position*

Enter reason for leaving if not currently employed.

If participant is currently employed, enter "N/A".

Employment End Date*

Enter as YYYYMMDD or "N/A"

What Trade Does Pre-Apprenticeship Tie to?*

Select all that apply. NYS apprenticeable trades: https://labor.ny.gov/apprenticeship/general/occupations.shtm

Select

Name of Person Entering Data on this Form*

Enter as First Name Last Name.

Person Entering Data on this Form's Phone Number*

Enter phone number in the following format 555-555-5555.

Person Entering Data on this Form's Email*

Signed Information Release Form*

Each participant must sign a Participant Information Release Form.

Check this box to certify it has been signed and attached.

PA Intake Verification*

I certify that to the best of my knowledge, the provided information is true and accurate.

File Attachments*

Please attach the signed "Participant Information Release Form."

Please save as a single PDF and use the file naming convention "date_participantlastname_release.pdf" such as "20200312_Doe_release.pdf" (date should be date of submittal).

Drag and drop files here or

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