CES Partner Information Form 
Date: 
Name of Agency: 			
Website: 
Primary Contact Person: 	
Title: 
Phone/E-mail: 
Services Provided 
Who do you provide services to? (Disability type, age range, education, work history, approximate number of placements per year) 
What are the most significant employment challenges for the consumers that you serve? 
What type of employment related services do you provide? (job club, supported employment, on the job training, etc.) 
Staff 
What staff members work in the employment department? (Please provide title, job functions, and number of staff members) 
How does staff currently track employer development and placement activities? (paper files, database, etc.) 
What barriers and challenges do staff face? 
Employer Development 
How does the staff obtain job leads? 
What is your policy regarding employer outreach and networking both before and after placement? 
History of Collaboration 
Has your agency participated in other employment-related collaborations? If yes, what were the participation requirements