Veterans and Eligible Spouses or Persons Triage Form

Workforce Connections | Updated 04/21/2020

This form is used to determine your eligibility for additional services and is intended solely to provide priority to Eligible Veterans and Eligible Spouses or Persons that meet certain criteria. This information is being requested on a voluntary basis and will be kept confidential. Refusal to provide the information will not subject you to any adverse consequences.

Please contact our Workforce Connections Manager, Marcy Kasner at mkasner@larimer.org or (970) 498-6659 with any questions.

Date *

Date

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

E-mail *

Required*

Veteran Status *

	Yes	No
Have you served on active duty 181 or more days and do you have other than a dishonorable discharge? Or: a) Were you discharged or released from active duty because of a service-connected disability? b) Were you a member of a reserve component under an order to active duty during a period of war or in a campaign or expedition for which a campaign badge is authorized and were discharged or released from such duty with other than a dishonorable discharge? c) Were you discharged or released from active duty by reason of a sole survivorship discharge?
Are you the spouse of: a) a totally disabled or deceased veteran whose disability or death was service-connected? b) an active duty service member who is currently listed as missing in action or forcibly detained by a foreign power or hostile entity for more than 90 days? c) a 100% disabled eligible veteran in which you are the caregiver? d) a Wounded Warrior assigned to a Warrior Transitioning Unit (WTU) or Military Treatment Facility (MTF) in which you are the caregiver?

Needs Determination for DVOP Services: *

	Yes	No
Do you have a service connected disability or pending claim? (Entitled to compensation from the VA or was discharged or released from active duty for a service-connected disability?)
Are you a Vietnam Era Veteran? This is defined as active military service in the Republic of Vietnam between February 28, 1961 and May 7, 1975, or service between August 5, 1964 and May 7, 1975.
Are you currently homeless?
Are you a transitioning service member who has who has not met career readiness standards and in need of individualized career services as indicated by a DD Form 2958, between the ages of 18-24, or is being involuntarily separated through a Service reduction-in-force?
Have you ever been incarcerated?
Do you lack a high school diploma or equivalent certificate?
Are you unemployed or do you receive public assistance under one or more federal, state, or local income based public assistance programs; ex: TANF, SNAP (food stamps), SSI, or GA?
Are you a veteran between the ages of 18-24 years old?
Are you a recently-separated service member, who at any point in the previous 12 months has been unemployed for 27 or more weeks?
Are you a Wounded Warrior assigned to a Warrior Transition Unit or Military Treatment Facility?

Thank you for your service to our country.