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Entry Employment Experience Program
Education Component: Initial Interview
Name: _________________________Date:_________ Age:_______
First Language:___________________________________________
Educational background:____________________________________
Last school attended:______________________________________
Last grade attended: Last grade completed:_____________________
Date last attended:________________________________________
Self-Rating
My reading skills are: Excellent | Good | Fair | Need Work
Explain your rating:
My math skills are: Excellent | Good | Fair | Need Work
Explain your rating:
My writing skills are: Excellent | Good | Fair | Need Work
Explain your rating:
The following questionnaire is designed to provide you with
an opportunity to communicate with the education instructor
about what youd like to learn and how you learn best.
The best learning takes place in a supportive environment
where people are able to discuss ideas and problems as they
arise. Communication is the mutual responsibility of all involved
in the learning process and this questionnaire will begin
that communication process.
Career/Work Goals
I would like to
attend college to study____________________________________
attend a training program for _______________________________
get a job as a __________________________________________
The thing I need to work hardest on to achieve my career
and educational goals is_______________________________________________
Personal Goals
The following questions give you an opportunity to describe
other things about yourself besides your educational and career
goals. Please complete all statements and give as much information
and explanation as possible.
In my free time, I like to
_____________________________________________________
Some of my characteristics which I like are
_____________________________________________________
Some obstacles that keep me from doing things Id like
to do are
_____________________________________________________
Other things I would like to learn (please describe any experience
with the following)
managing money effectively
_____________________________________________________
understanding pricing, discounts, etc.
_____________________________________________________
registering to vote
_____________________________________________________
getting a library card
_____________________________________________________
learning to use the library
_____________________________________________________
getting involved in community activities
_____________________________________________________
learning about careers such as
_____________________________________________________
protecting my health effectively
_____________________________________________________
managing time effectively
_____________________________________________________
Please add at least one other thing you would like to learn
_____________________________________________________
Please list at least one thing which you can teach others
_____________________________________________________
Do you learn better working with others or alone? Please
explain.
_____________________________________________________
Do you learn best by watching someone else, by reading about
something, by listening to someone or by doing something yourself?
Explain, and if possible, give an example of something you
learned well and how you learned it.
_____________________________________________________
Interests
There are no right or wrong answers for the following questions.
The purpose is to identify possible interests and learning
styles for each person.
My favorite subject in school was because
_____________________________________________________
The most memorable thing I ever learned in school was
Ive always wanted to learn or do
_____________________________________________________
Name at least two things youve seen or heard about
and would like to understand better
_____________________________________________________
Would you rather read a good story or a news magazine? Why?
_____________________________________________________
Would you rather listen to an older relative talk about your
family history or listen to the news? Why?
_____________________________________________________
Would you rather discuss personal and social values and how
they fit into your life or how the body works? Why?
_____________________________________________________
Name at least two other things you enjoy reading about or
discussing (some examples might be hobbies, places youve
lived, sports, current events or news youre concerned
about, health, movies, music, etc.)
_____________________________________________________
Life Skills
Describe a situation where you were able to help yourself
or someone else accomplish something (some examples may include
resolving a conflict, doing a budget, doing something positive
for your health, etc.)
_____________________________________________________
Have you ever been unable to do something you really wanted
to do because you didnt have the necessary skills or
information? Please describe
_____________________________________________________
Are there forms, labels, documents, reference books, maps,
etc. which you would like to learn more about?
_____________________________________________________
Personal Reading and Writing
I would like to read for enjoyment (please list anything youve
read recently in any category)
adventure_______________ mystery _______________
romance _______________history _______________
sports _______________music_______________
poetry _______________religion_______________
horror _______________
TV & movies _______________true-life stories _______________
self-help _______________how-to hobbies parenting ____________
science fiction_____________magazines newspapers ____________
I have written or would like to write:
poems _______________songs_______________
stories _______________ journal/diary____________ essays_______________
school papers _______________
news articles _______________letters _______________
advice to others _______________
Other reading or writing skills you have or would like to
have:
The best thing I ever read was
_____________________________________________________
The best movie or TV program I ever saw was
_____________________________________________________
I also enjoy:
cartooning _______________painting_______________
drawing _______________singing _______________
other _______________
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