EnrolmentsTitleMrsMissMsMrDrOtherFirst NameLast NameYour current ageStreet AddressPost CodeEmail AddressPhoneWelsh LanguageRead WelshSpeak WelshWrite WelshUnderstand WelshYour preferred languageEnglishWelshGender IdentityGender on Birth CertificateMaleFemaleEthnicityWhite WelshWhite BritishWhite IrishWhite OtherMixed – White and Black CaribbeanMixed – White and Black AfricanMixed - White and AsianMixed – OtherBlack or Black British – AfricanBlack or Black British – CaribbeanBlack or Black British – OtherAsian or Asian British – IndianAsian or Asian British –PakistaniWhiteAsian or Asian British –BangladeshiWhiteAsian or Asian British –OtherWhiteChinesePrefer not to sayOtherWhen did you last work? Leave blank if you've never workedPlease click on all that apply to youI am a full-time carerI live in a jobless householdI have a work limiting health conditionI'm homeless or a rough sleeper.Recently lost job due to redundancySingle adult householdHave a disabilityHave dependent childrenHow did you hear about this project?Skills for employmentPlease select an option that applies to you.1. I don’t believe I have any skills that are relevant and will secure me employment.2. I would like to get the skills but I don't know where to find help.3. I am working towards gaining the skills to help me find employment.4. I believe I have some of the skills I need to secure employment but there is room for improvement.5. I believe I have all the relevant skills I need to secure employment.Confidence and motivationPlease select the option that applies to you.1. I have no confidence or motivation and do not believe that there are any sources of support to help me find employment or further learning opportunities.2. I have no confidence or motivation, but I believe that I could change this if I found suitable support and guidance to help me.3. I am currently receiving some guidance and support to help me gain more confidence and motivation but I feel that there is room for improvement.4. I am fairly confident and motivated, but I still have some self-doubt when applying for employment or further learning opportunities.5. I am confident and motivated and feel that I am ready for future employment and learning opportunities.Job SearchPlease select the option that applies to you.1. I have no idea where to start in looking for jobs or opportunities.2. I'm concerned that I don't know where to find jobs and would like help.3. I am currently receiving some guidance and support to help me with my job searching skills because I have some knowledge but there is definitely room for improvement4. I am fairly good at identifying opportunities, but I occasionally struggle with application processes from time to time.5. I am confident in my ability in identifying and applying for appropriate positions.Self-reflectionPlease select the option that applies to you.1. I do not feel positive about my future.2. I need some support to help me to gain a more positive mind-set, but I am not sure where this is available.3. I am hoping to make the necessary changes towards a more positive future.4. My outlook has led me to make some improved changes to my life.5. I feel positive about my futureAspirationsPlease select the option that applies to you.1. I do not know what I want to do in the future and have no plans.2. I have gained some aspiration but still feel I need some guidance.3. I am aware of what I would like to do and know the steps I need to take to achieve it.4. I feel inspired and have made changes in my life5. I am fully committed to what I want to do in the future and feel that I can now achieve this.ResponsibilitiesPlease select the option that applies to you.1. I feel that my responsibilities hinder my chances of securing employment.2. I understand that there are support networks that are available to me.3. I have made connections with the support groups that are available to me.4. I am currently accessing relevant support which are allowing me to explore future possibilities.5. I understand the steps I must take to become independent in my own right.Age BarriersPlease select the option that applies to you.1. I feel that my knowledge and skills are out of date for the current job market.2. I want to bring my knowledge and skills up to date but don't know what opportunities are available to me.3. I am aware of the opportunities and I am looking to access them.4. I have identified where I need to build my knowledge and skills and have a plan in place to address this.5. I acknowledge the experience I have would be valued in any work place.Changing the patternPlease select the option that applies to you.1. I don't see the point in trying to change anything - my experience tells me that it doesn't help.2. I want to make a better future for myself but am worried that I will not have the support from the rest of my household.3. I am aware of the value of opportunities available to help me gain employment.4. I understand that employment is the routine to a more positive life.5. I am accessing the opportunities available to help me gain employment and am trying to educate others in my household.Ethnicity BarriersPlease select the option that applies to you.1. I feel my ethnicity is hindering my employment choices.2. I feel that my ethnicity is hindering my employment choices, but if there was specialist support available I might feel differently.3. I feel my ethnicity is a barrier to employment, but I am feeling more positive after accessing specialist support and advice services.4. I don't feel my ethnicity is a barrier but feel employer still might.5. I do not see my ethnicity as a barrier to employmentWell-beingPlease select the option that applies to you.1. I feel my condition limits the employment opportunities I can consider.2. I need support in addressing ways to increase my employability and identify ways to manage my condition to sustain employment.3. I have identified my employability strengths and areas of improvement.4. I have found solutions for managing my condition enabling me to sustain employment.5. I am confident that my condition will not limit my employment opportunities.SubmitPlease do not fill in this field.