Referral Part B completed by Title I Workforce Staff below Title II Submission Click to enter information Title II Submissions Information: Part A Submission ID Local WorkSource AreaChoose an Area1 – Northwest2 – GA Mountains3 – City of Atlanta4 – Cobb5 – DeKalb6 – Fulton7 – Atlanta Regional8 – Three Rivers9 – Northeast GA10 – Macon – Bibb11 – Middle GA12 – Central Savannah River Area13 – East Central GA14 – Lower Chattahoochee15 – Middle Flint16 – Heart of GA17 – Southwest GA18 – Southern GA19 – CoastalTestAtlanta RegionalNot ApplicableFayetteGwinnettHenryRockdaleCherokeeClaytonDouglasParticipant Name First Last Participant Phone NumberParticipant Email Referring Provider Referring Provider Email Adult Education Services Start Date MM slash DD slash YYYY Adult Education Services End Date MM slash DD slash YYYY Training Goal Reason for the Referral Participant Priority of Service InformationPlease check one or more of the boxes below: Participant is receiving Adult Ed HSE services with no high school diploma or its equivalent – not currently enrolled K-12 system Participant is receiving Adult Ed services due to TABE test results at or below 8.9 grade level Participant is receiving Adult Ed services due to being an English Language Learner Part B – To be completed by Title I Workforce StaffTitle I and Adult Education Co-Enrolled(Required) Yes No If no, choose reason participant is not eligible for co-enrollment(Required) Participant did not meet Title I Adult basic eligibility criteria: authorize to work in the U.S., selective service (male), unemployed/underemployed. Participant did not follow through. Participant is eligible, however funds are not available, individual placed on a waiting list (list eligibility determination date). Other If Other, please describe.Current Eligibility Determination Valid Through Month Day Year Is transportation reimbursement covered by Title I(Required) Yes No If childcare is needed, a CAPS referral has been made(Required) Yes No Is childcare reimbursement covered by Title I(Required) Yes No List any other Supportive Services covered by Title I: Breakdown of costs needed for training:Tuition $(Required)Uniforms $(Required)Testing Fees $(Required)Books $(Required)Tools $(Required)Other Service (Describe) Other Service Cost $Total Costs covered by Title I Funds $Workforce Staff Signature(Required)Date MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
