?? 000
M ( ) F ( ) EC ( )
- 30
( ) 30 45 ( ) + 45 ( )
DATE
|
M ( ) F ( ) EC ( ) - 30
( ) 30 45 ( ) + 45 ( ) |
PIEEC of
..
Facilitators Name
.
_fichiers/image001.gif)
1.
IDENTITY
Mr ( )
Mrs ( ) Miss ( )
NAME
SURNAME
..
ADDRESS
..
Telephone Number
..
2.
INDIVIDUAL INFORMATIONS
NATIONALITY 1.
. Eventually COUNTRY of ORIGIN 2.
Date of BIRTH
Place
of BIRTH
STATUS Alone
( ) Married ( ) Separated ( ) Divorced ( ) Widow ( )
Number of Children still at
home :
..
Level of practices regarding language of
hosting country
READ (
) ( ) ( ) ( ) ( )
WRITE (
) ( ) ( ) ( ) ( )
SPEAK (
) ( ) ( ) ( ) ( )
-1 2
3 4 +5
3.
END of COMPULSORY EDUCATION
At which age did you left
School ?
Reasons for leaving School ( ) ECONOMIC
Reasons ( ) HEALTH
( ) FAMILY
Reasons ( ) Other Reasons
( ) INSUFFICIENT
LEVEL of Knowledge to go further
Optional COMMENTS
..
..
4.
Informations regarding TEACHED MATTERS Liked Didnt like
National Language ( ) ( )
Mathematics ( ) ( )
Foreign
Languages ( ) ( )
ICT (
) ( )
Sports (
) ( )
5.
School Life Liked ( ) Didnt
liked ( )
Optional COMMENTS
..
..
6.
EXPECTATIONS regarding New
APPRENTICESHIPS
CHOICE
1 2 3
National Language ( ) ( ) ( )
Mathematics ( ) ( ) ( )
Foreign Languages (
) ( ) ( )
Sciences and Technics (
) ( ) ( )
ICT (
) ( ) ( )
ARTS and CULTURE ( ) ( ) ( )
Please could you be more precised
regarding ICT
Optional COMMENTS
..
..
7.
Which PURPOSES are guiding these new
apprenticeships ?
( ) for
SELF-DEVELOPMENT (
) To upgrade KNOWLEDGES
( ) To
help your Children (
) To Search a JOB
( ) For
Social Inclusions Reason (
) Other Reasons
Optional COMMENTS
..
8.
Which type of new products would you
like to find in your PIEEC Catalogue ?
..
CHECK LIST to be sure that this visitor belong to ACRE target groups
1.1 The
adult learner is:
[ ] out of
Compulsory Education,
[ ] in
difficulty regarding integration,
[ ] is
volunteer to start this program.
1.2 Environment
[ ] Urban Area
[ ] Rural Area
[ ] Mixed Area
(Suburbs)
1.3 Socio
and/or Economic Disadvantages in his/her area of life
[
] High Unemployed Rate,
[
] Difficulties to access to proximity
Services such as healthcare, shopping, administrations,
[ ]
Difficulties to access to Education (training centres, library, theatre,
culture
).
1.4 Difficulties to be integrated
[ ] searching a
job,
[ ] difficulty
regarding the language of the hosting country,
[ ] lack of
qualification(s),
[ ] too young,
[ ] over 45
years old,
[ ] without
permanent address,
[ ] ex-inmates,
[ ] ethnic
problems,
[ ] behaviour
problems,
[ ] problems of
health,
[ ] lack of
autonomy,
[ ] problems of
drugs, alcohol, other addiction products.
The
-
all
three items at point 1.1
-
at
least 1 item at point 1.2
-
at
least 1 item at point 1.3
-
at
least 3 items at point 1.4