IND (1) 1. PERSONAL DETAILS File Status: Dormant Open Closed PI Ref: Lot*: (if your PI has more than one Lot insert Lot name for the individual) First Name*: 2. REGISTRATION / CONSENT Date of Registration Meeting*: / /20.... Consent to record personal data* No Yes Consent to record sensitive data* No Yes Consent to share data with local service providers* Consent for future contact for surveys/evaluations* No Yes No Yes Personal Action Plan Agreed* No Yes Male or Female* Male Female Date of birth / / DOB is mandatory if aged 15-24 Age Band* 15-24 25-35 36-45 46-55 Over 55 How did the Individual hear about SICAP services* (Select one option only) Last Name*: Mobile No*: Email*: Home No: Address*: County / Dublin Postcode*: 3. PROFILE Engagement in Goal 1 Activity Friends/Family Local Community Group Govt. body, state agency or other relevant organisation Publicity/Information Campaign Social Media/Website If Govt. body, state agency or other relevant organisation please specify* Community Training Centre Education & Training Board HSE INOU Intreo Local Authority Local Employment Service Local Enterprise Office Other agency/body Specify Other * School Youthreach 4. STATUS AT REGISTRATION PRINCIPAL ECONOMIC STATUS* AT REGISTRATION (Select one option from the 3 options (Unemployed, Economically Inactive, Employed) plus answer any sub-questions) Unemployed Live Register less than 6 months Live Register 6-12 months Live Register 13-24 months Live Register more than 24 months Economically Inactive Unemployed less than 6 months but not on Live Register Unemployed 6-12 months but not on Live Register Unemployed 13-24 months but not on Live Register Unemployed more than 24 months but not on Live Register Economically Inactive (If Yes. Select one option from the list below)* Engaged in Family Duties Full Time Student if Yes answer BTEA question: BTEA: Yes No Retired Illness/Disability Other (Specify Other)* Employed Employed: State Supported Employment Scheme (If Yes Answer both question below)* Employment Scheme: CE CSP Gateway JI JobBridge RSS Tús Other Low Income Worker/Household: Yes No (Specify Other)* Employed: Part-Time (If Yes Answer 3 questions below)* Underemployed: Yes No Permanent: Yes No Low Income Worker/Household: Yes No Employed: Full Time (If Yes Answer both questions below)* Permanent: Yes No Low Income Worker/Household: Yes No Self Employed: (If Yes Answer question)* Low Income Worker/Household: Yes No * = Mandatory Field (must not be left blank)
HIGHEST LEVEL OF EDUCATIONAL ATTAINMENT* AT REGISTRATION (Select one option only) IND (2) No Formal Education Primary (NFQ 1 or 2) Lower Secondary (NFQ 3) Technical or Vocational (NFQ 4 or 5) Upper Secondary (NFQ 4 or 5) Advanced Certificate/Completed Apprenticeship (NFQ 6) Higher Certificate (NFQ 6) Ordinary Bachelor Degree/National Diploma (NFQ7) Honours Bachelor Degree/ Professional Qualification (NFQ 8) Postgraduate Diploma or Degree (NFQ 9) Doctorate (NFQ10) 5. TARGET GROUP/BACKGROUND Lone Parent* Yes No Person with a Disability* Yes No Nationality* (Select one option only) Ireland UK Europe (Specify Country) Africa New Communities* Asylum Seeker Migrant experiencing socio-economic disadvantage Refugee Ethnic/Cultural * (Select one option only) Asia North America & Oceania Rest of World Yes No (If Yes Select one option only*) White Irish Irish Traveller Any Other White Asian or Asian Irish Chinese Any Other Asian Black or Black Irish African Any Other Black Roma Other, including mixed background (Specify Other) Has the Individual experienced discrimination in accessing/participating in mainstream services? Yes No 6. HOUSEHOLD SITUATION Single Adult Household* Yes No Jobless Household* Yes No Dependent Children Living in Household* Yes No In Financial Difficulty* Yes No If the person is in financial difficulty are they in receipt of Financial Services Yes No Homeless or Affected by Housing Exclusion* Yes No 7. YOUTH RELATED INFORMATION Young Person* Yes No (automatically selected based on age (<25) at time of registration) Status of Youth* (Select one only) Still in school but identified as at risk of dropping out Completed compulsory education + NEET Already dropped out of school + NEET None of the above 8. DECLARATION I confirm that the information provided above to determine my eligibility for the Social Inclusion and Community Activation Programme (funded by the Department of the Environment, Community and Local Government and co-funded by the European Social Fund/Youth Employment Initiative), is true and accurate to the best of my knowledge. Signed: Date:
9. SUPPORT INTERVENTIONS SICAP IRIS: INDIVIDUAL BENEFICIARY TEMPLATE: V7 (23.09.16) (At least two interventions must be inserted in current year) IND (3) Intervention Types: One to One meeting, Group Meeting, Workshop, Information Session Support Types: Goal 2/3: Personal Action Plan preparation Personal Action Plan Agreed? (Please see Sect. 2: Registration/Consent) Goal 2: (G2.2) Support in accessing LLL (guidance, counselling, etc.), (G2.2) Support in accessing community childcare, (G2.2) Follow-up supports to remain in LLL course Goal 3: (3.1) Career advice and guidance supports, (3.1) Pre-employment supports, (3.1) Job ready/activation supports, (3.1) Support in accessing training/specific skills or other labour market activities, (3.1) Self-employment supports, (3.2) Support in accessing self-employment grants, (3.1) Self-employment follow-up supports Action*: Date* Intervention Type* (see above) Support Type* (see above) Staff Member / Comment * = Mandatory Field (must not be left blank)
SICAP IRIS INDIVIDUAL BENEFICIARY TEMPLATE: V7 (23.09.16) IND (4) 10. OUTPUTS (Select Relevant outputs based on progression of the Individual) G2.2 In Receipt of a Goal 2 Educational Support (Intervention) Progression along the Education continuum Name of Course* (Course template required) Course Outcome Successfully Completed Some modules completed successfully Unsuccessfully Completed Did not Complete G2 Referred to LLL/FET provider Type of LLL/FET Service* PLC Course VTOS BTEI Adult Literacy Other (specify) Outcome*: Participating in LLL (Other LLL/FET provider) No Outcome G2 Referred to other services which impact accessing LLL G3.1 Work Experience/Work Placement Programmes (Intervention) Employment Scheme: CE CSP Gateway JI JobBridge RSS Tús Work Experience Other Start End (Specify Other)* Name of Employer Occupational Group* Outcome* Successfully Completed Unsuccessfully Completed Did not Complete G3.1 Pre-Apprenticeship/Apprenticeship/Traineeship Programme (Intervention) Name of Programme* Start Date* / / 20 End Name of Employer* Trade* Outcome* Successfully Completed Unsuccessfully Completed Did not Complete Current Economic Status Current Educational Attainment Level G3.1 Participating in Labour market training and occupational specific skills (Intervention) Name of Course* (Course template required) Course Outcome* Successfully Completed Some modules completed successfully Unsuccessfully Completed Did not Complete Current Economic Status Current Educational Attainment Level G3.2 Funding given by SICAP Implementer to assist with self employment start up Type of Service* Health Supports Drug Assistance Citizen s Rights Financial Advice Housing Provision Grant Amount* Grant Category* G3 Referred to other services which impact on employability and employment Type of Service* Health Supports Drug Assistance Citizen s Rights Financial Advice Housing Provision G3 Referred to other employment activation services Activation Service* Intreo LES Jobs Club Other (specify) Outcome*: Engaged in activation service (Other employment activation service) No Outcome Current Economic Status Current Educational Attainment Level G3.2 Referred to other self-employment/social entrepreneurship training and supports Type of Activation Service* Enterprise Ireland Local Enterprise Office Other (specify) Outcome*: Engaged in training or supports (Other self-employment/social entrepreneurship service) No Outcome Current Economic Status Current Educational Attainment Level G3.1 Progressed into Employment Employer* Start Occupational Group* Job Type* Full Time Part Time Hourly Rate* Still in Employment after 6 mths Yes No No response Current Economic Status G3.2 Progressed into Self Employment Enterprise Name* Sector* In receipt of DSP Enterprise Allowance* BTWEA STEA Not eligible Start Business Type* Sole Trader Partnership Limited Company Number of Jobs Created: Full-time Part-time Business still operating after 12mths Yes No No response Current Economic Status
ESF/YEI Participants Only ESF/YEI PARTICIPANTS ONLY (Aged 15-24 years) IND (5) 11. RESULT INDICATORS FOR ESF/YEI PARTICIPANTS ONLY Exited YEI Intervention* Exit _ Immediate result indicators for ESF/YEI participants upon leaving (up to 4 weeks after Exit Date)* Completed the YEI supported intervention Engaged in job searching upon leaving In Education/training upon leaving Received an offer of employment, continued education, apprenticeship or traineeship upon leaving Gained a qualification upon leaving In employment/self-employment upon leaving Longer-term result indicators for ESF/YEI participants six months after leaving (Exit Date)* Improved labour market situation six months after leaving In continued education, training programmes leading to a qualification, an apprenticeship or a traineeship six months after leaving In employment six months after leaving In self employment six months after leaving