LBS LEARNER STATISTICAL TRACKING SHEET

GENERAL INFORMATION
Name: Previous Last Name:
Mailing Address:
Postal Code: Phone Number:
E-mail Address:
Gender: checkbox Male checkbox Female Date of Birth:
Income Source checkbox OW checkbox ODSP checkbox EI checkbox Employed checkbox WSIB checkbox Other
Referred to Program by checkbox OW checkbox EI checkbox Other (specify):
INITIAL ASSESSMENT
Date: Communications Level 3 4 5 IV Math Skill 3 4 5 IV
Long Term Goal: checkbox Employment checkbox Training/Education checkbox Independance
Anticipated Start Date: checkbox None
Reason for the Delay: checkbox Wait List checkbox Client Delay checkbox No Show
RE-ASSESSMENT
Date: Communications Level 3 4 5 IV Math Skill 3 4 5 IV
REGISTRATION
Date: Status: checkbox Full Time checkbox Part Time hours per week
Short Term Goal checkbox Employment checkbox Training/Education checkboxIndependance
Revised: checkbox Employment checkbox Training/Education checkboxIndependance
checkbox LBS - Date: checkbox OBS/ACE - Date: checkbox Other
EXIT
Date: Communications Level 3 4 5 IV Math Skill 3 4 5 IV
Reason: checkbox Left after assessment checkbox Attained LBS Goal checkbox Learner initiated checkbox College initiated
Status: checkbox Other LBS checkbox Training or Education
checkbox Lost contact checkbox Employed checkbox Not employed checkbox Volunteer
3 MONTH FOLLOW-UP
Date:
Status: checkbox Other LBS checkbox Training or Education
checkbox Lost contact checkbox Employed checkbox Not employed checkbox Volunteer
6 MONTH FOLLOW-UP
Date:
Status: checkbox Other LBS checkbox Training or Education
checkbox Lost contact checkbox Employed checkbox Not employed checkbox Volunteer