APPENDIX B
SURVEY INSTRUMENT
POST VOCATIONAL REHABILITATION EXPERIENCES STUDY (PVRES)
DRAFT QUESTIONNAIRE – PAPER VERSION
May 9, 2007
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this information collection is estimated to average 49 minutes per response, including the time to review the instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Steve Zwillinger, Rehabilitation Services Administration, U.S. Department of Education, 550 12th Street, SW, Washington, DC 20202.
SECTION A. EMPLOYMENT
Enter today’s date: □□ □□ □□□□
This survey is about things that happened over the past year. Please think about the time period between today and the same month last year. Read each question carefully. After answering, follow the directions to the next appropriate question. Please write legibly. You may want to ask for help if you don’t know the answers to the questions.
The first questions are about work.
A1. Have you ever worked for pay?
(Count self-employed or owning your own business as working for pay.)
Yes Go to question A2
No Skip to question A26, page xx
A2. Have you worked for pay since this time last year?
Yes Go to question A3
No Skip to question A26, page xx
A3. How many jobs have you held since this time last year?
NUMBER OF JOBS
A4. Are you currently working for pay?
(Do you have a job now that pays you money or gives you a paycheck?)
Yes Skip to question A5a
No Go to question A5
A5. What was your most recent paid job?
Skip to question A8
MOST RECENT JOB:
A5a. Are you working more than one job now?
(Only include jobs you work for pay.)
Yes Go to question A5b
No Skip to question A7
A5b. How many jobs do you work now?
NUMBER OF JOBS
A5c. Do you typically work more hours per week on one job than the other?
Yes Go to question A5d
No Go to question A5e
A5d. Which job do you or did you typically work the most hours?
JOB WORKED THE MOST HOURS
A5e. Which job have you held the longest?
JOB HELD THE LONGEST
A7. How many hours a week do you usually work? If you work more than one job, include all jobs. Include overtime if you usually work overtime.
HOURS PER WEEK
A8. Since this time last year, how many months did you work?
NUMBER OF MONTHS WORKED
If you are currently working, the next questions are about your current job. If you have more than one job answer for the job you worked the most hours since this time last year.
If you are not currently working, answer the next questions thinking about your most recent job.
Most important, you should answer all the questions in this survey thinking about the same job. We will call it your “main” job.
A9. Do you or did you work for a community rehabilitation program or a workshop?
(Answer the question for your “main” job.)
Yes
No
A10. Which of the following best describes your employer for your “main” job?
CHOOSE ONLY ONE
A private business or organization
Local government
State government
Federal government
Self-employed
A11. Please describe the kind of business or industry. For example: food service, hospitality, manufacturing, construction, wholesale or retail trade, finance, insurance, real estate, services, public administration, agriculture.
BUSINESS OR INDUSTRY:
A12. Does your employer’s business, or your job, focus mainly on providing services to or promoting people with disabilities?
Yes
No
A13. What kind of work are you or were you doing on your “main” job? Write in your job title or describe your work. For example, waiter/waitress, high school math teacher, auto mechanic, stock clerk, data entry.
KIND(S) OF WORK:
A14. What are or were your duties at this job? For example: typing, keeping account books, filing, selling cars, operating a printing press.
DUTIES:
A15a. What is the address or the location where you work or worked at your “main” job? Provide as much information as you can. Examples of locations include shopping mall, office building, industrial park.
STREET ADDRESS:
LOCATION
CITY:
STATE:
ZIP:
A16. Did you have this same job at this time last year?
Yes
No
Not employed at this time last year
A17. How did you find your “main” job job?
Check only one.
By myself or through a friend
With help from the vocational rehabilitation
agency
Through a state employment agency or
One-Stop Center
Through an employment service
With help from a social service agency
Through some other type of agency
A18. When did you start working at your “main job’?
□□ □□□□
MONTH YEAR
A19. When did you stop working at your “main” job?
I am still working at this job Skip to question A22
□□ □□□□
MONTH YEAR
A20. Was it your choice or your employer’s decision that made you stop working?
My choice Skip to question A20c
My employer’s decision Go to question A20b
A20b. What was the main reason you stopped working?
Check only one.
I was laid off or the plant closed
I was fired
I had a temporary job that ended
It was seasonal work
Some other reason: Specify
Skip to question A21.
A20c. What is the main reason you stopped working?
Check only one.
I retired
I was sick or ill
I enrolled in school or a training program
I had family care responsibilities/homemaker
There was a change in a previously existing
disability/I acquired another disability
To obtain or keep health benefits (such as
Medicare or Medicaid)
To obtain or keep federal disability benefits
(such as SSDI or SSI)
I did not have reliable transportation
I was not able to get needed accommodations
I did not want to work
Some other reason: Specify
A21. Was the job:
Check only one.
Full-time
Part-time
A22. How many hours per week do you or did you usually work at your “main” job? Include overtime if you usually work overtime.
HOURS PER WEEK
A23. Since this time last year, on your “main” job, have you or did you work the following shifts?
Check one on each line.
|
YES |
NO |
a. The evening shift, for example, 5 pm to midnight |
□ |
□ |
b. The night shift, for example from midnight to 9 am |
□ |
□ |
c. The weekend shift |
□ |
□ |
A24. Since this time last year have you received any promotions on your “main” job?
Yes. Go to question A24a
No Skip to question A25
A24a. Did you receive an increase in pay?
Yes
No
A24b. Did you receive additional benefits with the promotion?
Yes.
No
A25. Since this time last year, would you say your responsibilities on your “main” job:
Increased,
Stayed about the same, or
Decreased?
If you are currently working, check here □ and skip to section B on page XX. Otherwise go to question A26.
A26. Have you spent any time looking for a job in the past 4 weeks?
Yes. Go to question A27
No Skip to question A28
A27. In the past 4 weeks, to look for work did you do any of the following?
Check one on each line.
|
YES |
NO |
a. Contact your state’s employment service office |
□ |
□ |
b. Ask friends or relatives |
□ |
□ |
c. Look through job advertisements in a newspaper or on the internet |
□ |
□ |
d. Contact the State Vocational Rehabilitation Agency |
□ |
□ |
e. Contact a local independent living center |
□ |
□ |
f. Contact a private employment agency or program |
□ |
□ |
g. Contact any employers in person, by mail, email or by phone |
□ |
□ |
h. Something else Please describe: |
□ |
□ |
A28. What is the main reason you are not working now? This might be the same reason you gave earlier for leaving work or a different reason. Is it because you:
Check only one.
Are retired
Are sick or ill
Are enrolled in school or a training program
Have family care responsibilities/homemaker
Cannot work due to a disability
Want to qualify for Medicare or Medicaid
coverage
Do not have reliable transportation
Are not able to get needed accommodations
Do not want to work
Some other reason? (specify)
SECTION B. DESCRIPTION OF DISABILITIES OR OTHER IMPAIRMENTS
This section asks about your health and any difficulty you may have with activities of daily life.
B1. Thinking of your physical, mental and emotional health would you say your health in general is…
Check only one.
Excellent
Very good
Good
Fair
Poor
B2. Activities of daily life include caring for oneself, doing manual work or tasks with your hands, walking, seeing, hearing, speaking, breathing, learning and working. Thinking back to this time last year, would you say that you now have:
Check only one.
Less difficulty with major activities of life than
you did then
About the same amount of difficulty
More difficulty
B3. Do you have a long-lasting, severe vision impairment? By long lasting we mean lasting 6 months or longer.
Yes Go to question B3a
No Go to question B4
B3a. Do you use an assistive device, the help of another person to read words or letters in print, or both?
Check all that apply
I use an assistive device
I use help from another person
I do not use either
B4. Do you have a long-lasting, severe hearing impairment? By long lasting we mean lasting 6 months or longer.
Yes Go to question B4a
No Go to question B5
B4a. Do you use an assistive device such as a hearing aid, the help of an interpreter or other person, or both?
Check all that apply
I use an assistive device
I use help from another person
I do not use either
B5. Do you have a long-lasting condition that makes it hard to walk, climb stairs, reach, lift, or carry?
By long lasting we mean lasting 6 months or longer.
Yes Go to question B5a
No Go to question B6
B5a. Do you use an assistive device, the help of another person, or both to walk, climb stairs, reach, lift or carry?
Check all that apply
I use an assistive device
I use help from another person
I do not use either
B6. Do you have difficulty learning, remembering, or concentrating because of a long lasting physical, mental or emotional condition? By long lasting we mean lasting 6 months or longer.
Yes Go to question B6a
No Go to question B7
B6a. Do you use the help of another person, an assistive device, or both to help you learn, remember or concentrate?
For example, to help you manage your money or read and understand the newspaper, by making a list of your job duties or reminding you when to do certain things.
Check all that apply.
I use an assistive device
I use help from another person
I do not use either
B7. Do you have difficulty dressing, bathing, or getting around inside the house because of a long lasting physical, mental or emotional condition? By long lasting we mean lasting 6 months or more.
Yes Go to question B7a
No Go to question B8
B7a. Do you use an assistive device, the help of another person, or both to do any of these activities?
For example, to dress, bath, or get around the house.
Check all that apply.
I use an assistive device
I use help from another person
I do not use either
B8. Do you have difficulty going outside the home alone to shop or visit a doctor’s office because of a long lasting physical, mental or emotional condition? By long lasting we mean lasting 6 months or more.
Yes
No
The next questions are about any difficulty you might have working.
B9. Do you have difficulty working at a job or business because of a long lasting physical, mental or emotional condition? By long lasting we mean lasting 6 months or more.
Yes
No
B10. Thinking back to this time last year would you say the severity of your condition or disability is
About the same,
More severe or
Less severe?
B11. What year did you first develop a disability? That is when was the onset of the condition or when did you first notice it as a disability?
□□□□
YEAR
SECTION C. WORKPLACE FEATURES
If you have not worked for pay since this time last year check here □ and skip to Section D on page XX.
The next questions are about accommodations you may have or may have had at your “main” job. This is the same job you answered questions about earlier.
If you are currently working, your “main” job is your current job. If you have more than one job your “main” job is the job you worked the most hours since this time last year.
If you are not currently working, answer the questions thinking about your most recent job.
C1. Do you have any problems getting around, or getting where you need to be, where you work ?
Yes
No
C2. When you are at work, do you use special equipment to get around?
Examples include a scooter or a wheelchair or some other special mobility equipment.
Yes
No
C3. Do you use special equipment or devices such as a modified workstation or seating, special pens, or other office furniture or supplies at work?
Yes
No
C4. When you do your work do you use any special devices to help communicate with other people?
Examples of these special devices are a voice synthesizer, communication board, TTY or a telecommunications device.
Yes
No
If you do not have a long lasting severe visual impairment check here □ and skip to question C7.
C5. Do you use anything such as special lighting, enlarged print materials, audio tapes or low vision aids when you do your work?
Yes
No
C6. Do you use specialized hardware or software in order to use a computer at your job?
Check one.
Yes
No
I do not use computer
C7. Do you have any of the following types of personal assistance at your “main” job because of a medical condition, impairment or disability?
Do not include supervisors as personal assistants. Only include co-workers if it is their job to provide personal assistance.
|
|||
|
YES |
NO |
|
a. A personal assistant to help with job related tasks or activities |
□ |
□ |
|
b. A personal assistant to help with personal care needs at work |
□ |
□ |
|
c. A job coach to help train you and supervise your work |
□ |
□ |
|
d. A reader, oral or sign language interpreter to assist you at work |
□ |
□ |
|
e. Other personal assistance Please describe: |
□ |
□ |
|
C8. Because of a medical condition, impairment or disability, do you personally have any of the following types of accommodations at your work? That is at your “main” job. |
|||
|
YES |
NO |
|
a. Do you have flexible working hours? This is a change in the length or the time of the workday. |
□ |
□ |
|
b Do you work from home via telephone or computer some or all of the time? This is sometimes called telecommuting. |
□ |
□ |
|
c. Do you share one job with another worker to cover one full-time job? This is also called job sharing. A full-time job is 35 or more hours a week. |
□ |
□ |
|
d. Do you have a compressed work week? That’s where you work full-time hours in a reduced number of days. A full-time job is 35 or more hours a week. |
□ |
□ |
|
e. Do you have paid or unpaid leave to care for dependents, for your education, or for other reasons? |
□ |
□ |
|
f. Do you have modified job duties? That is a change in the tasks you are assigned or how they are performed. |
□ |
□ |
|
C9. Because of a medical condition, impairment, or disability is there any workplace accommodation you feel you need but do not have at your “main” job?
Yes
No
If yes, please describe what you need
SECTION D. EARNINGS AND BENEFITS
If you have not worked for pay since this time last year check here □ and skip to question D5.
The pay questions are about your “main” job. This is the same job you answered questions about earlier.
If you are currently working, your “main” job is your current job. If you have more than one job your “main” job is the job you worked the most hours since this time last year.
If you are not currently working, answer the questions thinking about your most recent job.
D1. What is, or was, the usual amount of your paycheck? This is the amount you bring home or the net pay line on your pay stub. If you do not know the exact amount and do not have a pay stub, an approximate amount is acceptable.
$
AMOUNT
D1a. How often are or were you paid the amount you entered above? Was it:
Check only one.
Daily,
Weekly,
Every 2 weeks or twice a month,
Monthly, or
Annually?
Other. Please specify
D2. What is or was your pay before taxes and other deductions on your “main” job. Include your wages or salary. If you got bonuses include that. Count your tips. Also include commissions. Looking at your pay stub, this is your current gross pay.
$
AMOUNT
D3. What is or was your regular hourly pay on your “main” job? That is your pay before taxes are taken out.
$ .
PER HOUR
D4. Have you received any tips or commissions since this time last year on your main job?
Tips are cash given to you in addition to regular pay. They are sometimes called a gratuity. Commissions are additions to your regular pay based on your output or sales.
Yes
No
D5. What were your personal total earnings in 2006?
This would be found on your tax return or the W-2(s) submitted with your income tax return. This would be from wages, salaries, commissions, tips, and bonuses for all jobs you had in 2006. You will find this on line 1 of form 1040 EZ or line 7 of form 1040. It is on line or box number 1 on your W2.
$:
EARNINGS
If you have not worked for pay since this time last year check here □ and skip to question D8.
The next questions are about the benefits from your “main” job and other sources.
D6. Do you or did you have medical or health insurance through your employer at your “main” job? This would be through your business if you are self-employed.
Yes
No
D6a. Does your employer pay for the medical or health insurance, or do you pay some or all of the costs?
Do not include co-pays. Answer for insurance through your business if you are self-employed.
Employer pays all costs
I pay some costs
I pay all costs
D7. Do you have any of the following benefits through your job or employer? This would be through your business if you are self-employed.
Check one on each line.
|
YES |
NO |
|
a. Dental insurance |
□ |
□ |
|
b. Sick days with pay |
□ |
□ |
|
c. Paid vacation |
□ |
□ |
|
d. Transportation, a transportation allowance, or transportation discounts |
□ |
□ |
|
e. Long-term disability insurance |
□ |
□ |
|
f. A pension or retirement plan |
□ |
□ |
|
g. Any other non-medical benefit Please describe: |
□ |
□ |
The next questions are about your receipt of benefits not related your “main” job.
D8. Do you currently have medical or health insurance from any of the following sources?
|
YES |
NO |
|
a. Medicaid |
□ |
□ |
|
b. Medicare |
□ |
□ |
|
c. Medical insurance from other public sources |
□ |
□ |
|
d. Private insurance through your own employment |
□ |
□ |
|
e. Private insurance through other means, not including insurance through an employer. (Such as through your spouse or partner’s insurance, or through your retirement or pension program, or Medigap coverage.) |
□ |
□ |
D8B. Do you pay for your Medicaid insurance? (Some people pay to keep Medicaid coverage when they are no longer eligible for the benefit.)
I do not receive Medicaid
Yes, I pay for my Medicaid
No, I do not pay for my Medicaid
The next questions are about different sources of financial support.
D9. Since this time last year have you personally received SSDI (Social Security Disability Insurance)?
Yes Go to question D9a
No Go to question D10
D9a. Are you currently receiving SSDI?
Yes
No
D9b. How much do you receive or did you receive monthly? Please estimate if you do not recall the exact amount.
$
MONTHLY AMOUNT
D9c. For how many months during the past 12 months have you received SSDI?
NUMBER OF MONTHS
D10. Since this time last year have you personally received SSI (Supplemental Security Income) for the Aged, Blind, or Disabled?
Yes Go to question D10a
No Skip to question D11
D10a. Are you currently receiving SSI?
Yes
No
D10b. How much do you receive or did you receive monthly? Please estimate if you do not recall the exact amount.
$
MONTHLY AMOUNT
D10c. For how many months during the past 12 months have you received or did you receive SSI for the Aged, Blind, or Disabled?
NUMBER OF MONTHS
D11. Since this time last year have you personally received TANF (Temporary Assistance for Needy Families)? This transitional employment assistance program may have a different name in your state.
Yes Go to question D11a
No Skip to question D12
D11a. Are you currently receiving TANF?
Yes
No
D11b. How much do you or did you receive monthly? Please estimate if you do not recall the exact amount.
$
MONTHLY AMOUNT
D11c. For how many months during the past 12 months have you received or did you receive TANF?
NUMBER OF MONTHS
D12. Since this time last year have you personally received General Assistance from the state or local government?
Yes Go to question D12a
No Skip to question D13
D12a. Are you currently receiving it?
Yes
No
D12b. How much do you or did you receive monthly? Please estimate if you do not recall the exact amount.
$
MONTHLY AMOUNT
D12c. For how many months during the past 12 months have you received or did you receive General Assistance?
NUMBER OF MONTHS
D13. Since this time last year have you personally received Veteran’s Disability Benefits (VA)?
Yes Go to question D13a
No Skip to question D14
D13a. Are you currently receiving VA benefits?
Yes
No
D13b. How much do you or did you receive monthly? Please estimate if you do not recall the exact amount.
$
MONTHLY AMOUNT
D13c. For how many months during the past 12 months have you received or did you personally receive Veteran’s Disability Benefits?
NUMBER OF MONTHS
D14. Since this time last year have you personally received retirement income?
Yes Go to question D14a
No Skip to question D15
D14a. Are you currently receiving retirement income?
Yes
No
D14b. How much do you or did you receive monthly? Please estimate if you do not recall the exact amount.
$
MONTHLY AMOUNT
D14c. For how many months during the past 12 months have you received or did you receive retirement income?
NUMBER OF MONTHS
D15. Since this time last year have you personally received Worker’s Compensation?
Yes Go to question D15a
No Skip to question D16
D15a. Are you currently receiving Worker’s Compensation?
Yes
No
D15b. How much do you receive or did you receive monthly? Please estimate if you do not recall the exact amount.
$
MONTHLY AMOUNT
D15c. For how many months during the past 12 months have you received or did you receive Worker’s Compensation?
NUMBER OF MONTHS
D16. Since this time last year have you personally received any other cash benefit or support from public sources?
Yes Go to question D16a
No Skip to question D17
D16a. What is it called?
NAME OF CASH BENEFIT OR SUPPORT
D16b. Are you currently receiving it?
Yes
No
D16c. How much do you receive monthly? Please estimate if you do not recall the exact amount.
$
MONTHLY AMOUNT
D16d. For how many months during the past 12 months have you received cash benefits or support from public sources?
NUMBER OF MONTHS
D17. What is your most important source of financial support? This could be less than half of your total support. Is it…
Check only one.
Personal income such as earnings, interest,
dividends, rent payments,
Support from family and friends including
spouse’s income,
Public support/benefits,
Personal retirement income/pension or,
Some other source?
D18. Do you personally receive Section 8 housing assistance?
Yes
No
D19a. Does your household receive Food Stamps?
Yes
No
D19b. Does anyone in your household receive any form of public assistance, such as SSI, TANF, unemployment benefits, or Section 8 housing?
Yes
No
D20. During the past 2 months, did you generally have enough money each month to pay for the following?
Check one on each line.
|
YES |
NO |
|
a. Food |
□ |
□ |
|
b. Clothing |
□ |
□ |
|
c. Housing |
□ |
□ |
|
d. Traveling around for things like shopping, going to medical appointments, or visiting friends and relatives |
□ |
□ |
|
e. Social activities like movies or eating in restaurants |
□ |
□ |
SECTION E – COMMUNITY RESOURCES, SERVICES, SUPPORTS AND ATTITUDES
The next questions are about services or programs in the community that people sometimes use.
E1a. Have you received services from the state Vocational Rehabilitation agency, since this time last year?
Yes
No
E1b. Have you applied for services from the state Vocational Rehabilitation agency since this time last year?
Yes
No
E2Aa. Since this time last year did you participate in a day program? This is a place to go during the day to help deal with a disability. Sometimes called a club program or ACT.
Yes Go to question E2Ba
No Skip to question E2Ab
E2Ba. Is the program just for people with disabilities?
Yes
No
E2Ab. Since this time last year did you participate in a recreation, athletic, or exercise program?
Yes Go to question E2Bb
No Skip to question E2Ac
E2Bb. Is the program just for people with disabilities?
Yes
No
E2Ac. Since this time last year did you participate in a support group? Examples include peer support, a job club, drop-in, self help, a club program, Alcoholics Anonymous, Narcotics Anonymous, Overeaters Anonymous or other 12 step programs.
Yes Go to question E2Bc
No Skip to question E2C
E2Bc. Is the program just for people with disabilities?
Yes
No
E2C. Since this time last year have you used an independent living center?
Yes
No
E2D. Since this time last year have you used a state employment or a local “One Stop” center?
Yes
No
The next questions are about help you may have received finding and keeping a job.
E3Aa. Since this time last year did you receive job-search assistance, such as help looking for a job including training in job seeking skills?
Yes Go to question E3Ba
No Skip to question E3Ab
E3Ba. Did you receive this service from the State Vocational Rehabilitation Agency?
Yes
No
E3Ab. Since this time last year did you receive job-placement assistance that is, help getting a job?
Yes Go to question E3Bb
No Skip to question E3Ac
E3Bb. Did you receive this service from the State Vocational Rehabilitation Agency?
Yes
No
E3Ac. Since this time last year did you receive on-the-job supports such as a job coach or someone to check with you and your employer that everything is going well?
Yes Go to question E3Bc
No Skip to question E3Ad
E3Bc. Did you receive this service from the State Vocational Rehabilitation Agency?
Yes
No
E3Ad. Since this time last year did you receive personal assistance services including reader and interpreter services?
Yes Go to question E3Bd
No Skip to question E4
E3Bd. Did you receive this service from the State Vocational Rehabilitation Agency?
Yes
No
The next questions ask about services to help determine your needs and about different types of guidance you may have received.
E4Aa. Since this time last year did you receive assessment or testing services?
Yes Go to question E4Ba
No Skip to question E4Ab
E4Ba. Did you receive this service from the State Vocational Rehabilitation Agency?
Yes
No
E4Ab. Since this time last year did you receive diagnosis or treatment of impairments
or problems caused by your disability?
Yes Go to question E4Bb
No Skip to question E4Ac
E4Bb. Did you receive this service from the State Vocational Rehabilitation Agency?
Yes
No
E4Ac. Since this time last year did you receive vocational rehabilitation counseling and guidance?
Yes Go to question E4Bc
No Skip to question E4Ad
E4Bc. Did you receive this service from the State Vocational Rehabilitation Agency?
Yes
No
E4Ad. Since this time last year did you receive help with planning or obtaining benefits?
Yes Go to question E4Bd
No Skip to question E4Ae
E4Bd. Did you receive this help from the State Vocational Rehabilitation Agency?
Yes
No
E4Ae. Since this time last year did you receive advocacy or help to let you know your rights and what services are available to you?
Yes Go to question E4Be
No Skip to question E5
E4Be. Did you receive this from the State Vocational Rehabilitation Agency?
Yes
No
E4Af. Since this time last year did you receive any case management services?
Yes Go to question E4Bf
No Skip to question E5Aa
E4Bf. Did you receive this help from the State Vocational Rehabilitation Agency?
Yes
No
The next questions are about education or training you may have received since this time last year.
E5Aa. Since this time last year did you receive any educational training? For example, college or university training, occupational or vocational training, basic academic or remedial literacy training, training to get a high school equivalency or GED.
Yes Go to question E5Ba
No Skip to question E5Ab
E5Ba. Did you receive this training from the State Vocational Rehabilitation Agency?
Yes
No
E5Ab. Since this time last year did you receive any type of job-related training including on-the-job training, job skills training, job readiness training, or job seeking skills?
Yes Go to question E5Bb
No Skip to question E5Ac
E5Bb. Did you receive this training from the State Vocational Rehabilitation Agency?
Yes
No
E5Ac. Since this time last year did you receive training to help you to use Braille or sign language?
Yes Go to question E5Bc
No Skip to question E5Ad
E5Bc. Did you receive this training from the State Vocational Rehabilitation Agency?
Yes
No
E5Ad. Since this time last year did you receive any orientation and mobility training? This is training on how to move around or get about either outside or indoors.
Yes Go to question E5Bd
No Skip to question E6Aa
E5Bd. Did you receive this training from the State Vocational Rehabilitation Agency?
Yes
No
E6Aa. The next questions are about other types of assistance you may have received since this time last year. Since this time last year did you receive any training on how to use transportation?
Yes Go to question E6Ba
No Skip to question E6Ab
E6Ba. Did you receive this training from the State Vocational Rehabilitation Agency?
Yes
No
E6Ab. Since this time last year did you receive any transportation services? For example a van to take you to your job, help paying for a bus pass, or help with car repair costs.
Yes Go to question E6Bb
No Skip to question E6Ac
E6Ba. Did you receive this assistance from the State Vocational Rehabilitation Agency?
Yes
No
E6Ac. Since this time last year did you receive help with things like food or shelter, clothing needed for work, including uniforms? This could be in the form of cash or you could have been given clothes, food, etc.
Yes Go to question E6Bc
No Skip to question E6Ad
E6Bc. Did you receive this assistance from the State Vocational Rehabilitation Agency?
Yes
No
E6Ad. Since this time last year did you receive housing assistance such as Section 8 housing or help in finding housing?
Yes Go to question E6Bd
No Skip to question E6Ae
E6Bd. Did you receive this assistance from the State Vocational Rehabilitation Agency?
Yes
No
E6Ae. Since this time last year did you receive help caring for children or others in the household including child care?
Yes Go to question E6Be
No Skip to question E6Af
E6Be. Did you receive this help from the State Vocational Rehabilitation Agency?
Yes
No
E6Af. Since this time last year did you receive help in the home such as someone to do chores, deliver or cook meals?
Yes Go to question E6Bf
No Skip to question E7
E6Bf. Did you receive this help from the State Vocational Rehabilitation Agency?
Yes
No
E7. The following questions ask about medical services you might have received from any source. Since this time last year did you receive any of the following kinds of medical services?
Check one box on each line.
|
YES |
NO |
|
a. Surgery to correct a medical condition? |
□ |
□ |
|
b. Mental health counseling or substance abuse services including treatment for alcohol or drug abuse? |
□ |
□ |
|
c. Prescription drugs or other medical supplies? |
□ |
□ |
|
d. Medically needed assistive technology, such as a hearing aid, brace, artificial limb? |
□ |
□ |
|
e. Physical therapy or occupational therapy? |
□ |
□ |
|
f. Emergency treatment or hospitalization; for example, a visit to the emergency room or staying overnight in the hospital? |
□ |
□ |
E8. Do you have routinely scheduled meetings with a mental health, mental retardation, or developmental disability case manager?
Yes
No
Not applicable
E9. Have you ever used Ticket to Work?
Yes
No
Have not heard of Ticket to Work
The following questions are about family, friends, and other relationships that may support you.
E10a. If you need to talk, is there someone you can count on to listen to you.
None of the time,
Some of the time, or
Most of the time?
E10b. If you need to make a difficult decision, is there someone you can count on to listen and give good advice…
None of the time,
Some of the time, or
Most of the time?
E10c. Is there someone to help you in a crisis or in emergencies?
Yes
No
E11Aa. During the past 2 weeks did you get together socially with co-workers?
Yes Go to question E11Ba
No Skip to question E11Ab
I am not working Skip to question E11Ab
E11Ba. How many times did you do this during the past 2 weeks?
NUMBER OF TIMES
E11Ab. During the past 2 weeks did you get together socially with other friends or neighbors?
Yes Go to question E11Bb
No Skip to question E11Ad
E11Bb. How many times did you do this during the past 2 weeks?
NUMBER OF TIMES
E11Ac. During the past 2 weeks did you get together with any relatives not including those living with you??
Yes Go to question E11Bc
No Skip to question E12
E11Bc. How many times did you do this during the past 2 weeks?
NUMBER OF TIMES
E12. The next questions are about volunteer work. Have you done any work as an unpaid volunteer since this time last year?
Yes Go to question E12A
No Skip to question F1
E12A. Did your volunteer work provide you with opportunities to do any of the following?
Check one box on each line.
|
YES |
NO |
|
a. Interact with other people |
□ |
□ |
|
b. Learn and practice work skills |
□ |
□ |
|
c. Explore your own interests |
□ |
□ |
|
d. Belong to or feel part of a community |
□ |
□ |
SECTION F: EDUCATION AND TRAINING
This section is about your education and any training you may have received.
F1. Are you currently enrolled in an education or training program or have you been at any time since this time last year? (For example, college, a vocational or trade program, high school equivalency.)
Yes Go to question F1a
No Skip to question F5
F1a. What kind of program is this?
Check only one.
Elementary/secondary education
Equivalency certificate or GED
Associate degree program
Vocational/technical program
Apprenticeship or on-the-job training
Coursework/classes not leading to a degree
or certificate
4 year college or university
F5. What is the highest grade of school that you have completed?
Check only one.
No formal schooling
Elementary education (grades 1-8)
Some secondary education (grades 9-12),
but no high school diploma
High school graduate with a diploma or
certificate of attendance from a regular
education program
High school graduate with a diploma or
certificate of completion from a special
education program
Equivalency certificate or GED
Some post-secondary education, no degree
Associate degree
Vocational/technical certificate
Bachelor’s degree
Master’s degree or higher
F6Aa. Do you have a state-issued professional license?
You must pass an exam for this type of license.
Yes Go to question F6Ba
No Skip to question F6Ab
F6Ba. When did you obtain this?
□□ □□□□
Month Year
F6Ab. Do you have a certificate of completion of a formal apprenticeship program?
Yes Go to question F6Bb
No Skip to question F6Ac
F6Bb. When did you obtain this?
□□ □□□□
Month Year
F6Ac. Do you have a certificate of completion of a vocational/technical program?
Yes Go to question F6Bc
No Skip to question F6Ad
F6Bc. When did you obtain this?
□□ □□□□
Month Year
F6Ad. Do you have some other type of certificate not listed above?
Yes Go to question F6Bc
No Skip to question F6Ad
F6Bd. What type of certificate is it?
TYPE OF CERTIFICATE
F6Cd. When did you obtain this?
□□ □□□□
Month Year
SECTION G. HOUSEHOLD INFORMATION
This section is about you and your household.
G0. What is your date of birth?
□□ □□□□
Month Year
G1. What is your marital status?
Check only one.
Married
Widowed
Divorced
Separated
Never Married
G2a. Do you live alone?
Yes Skip to question G3a
No Go to question G2b
G2b. How many other people live with you at this time?
NUMBER OF PEOPLE
G3a. Do you have any dependents?
Yes Go to question G3b
No Skip to question G4
G3b. How many dependents do you have?
NUMBER OF DEPENDENTS
G4. Are you the person who owns or rents the home where you live?
Yes
No
G5A. Which one of the following best describes your current housing situation?
A private home or apartment. This includes
living independently, with family, roommates
or with other people Skip to question G6
A group living situation, institution or facility Go to question G5B
Some other situation Go to question G5B
G5B. Which one of the following best describes your housing situation?
Check only one.
Community residence, supported housing,
or group home Skip to question G6
Rehabilitation facility Skip to question G6
Mental health facility Skip to question G6
Nursing home Skip to question G6
Adult correctional facility Skip to question G6
Halfway house Skip to question G6
Substance abuse treatment center Skip to question G6
Homeless shelter, mission or flophouse,
homeless, transient, living on the street
or in a car Skip to question G6
Other Go to question G5C
G5C. Please check the one category below that best describes your housing.
Boarding school or other residential school
that is not a college
College dormitory or other college housing
Youth detention center
Military housing
Assisted living center or supervised apartment
Hospital or medical facility
Some other type of institution for people with
disabilities
Some other setting
G6. Have you been homeless at any time since this time last year?
Yes Go to question G6a
No Skip to question G7a
G6a. About how many days were you homeless since this time last year?
NUMBER OF DAYS
G7a. Are you of Hispanic, Latino, or other Spanish origin?
Yes
No
G7b. What is your race?
Check all that apply.
White
African American or Black
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
SECTION H: KEEPING IN TOUCH
We’ll be sending you a questionnaire again next year. We want to be sure we don’t lose track of you.
H1a. For our records please write your address.
Address:
City:
State:
Zip:
H2a. Where should we mail your check for $10?
Check here if it is the address above □ and go to question H2b
Address:
City:
State:
Zip:
H2b. How should your name appear on the check?
NAME
H3a. What is your e-mail address?
EMAIL ADDRESS
I do not have an email address □
H4a. What is the best phone number for us to use next year?
(_____) _____-_______________________________
BEST PHONE NUMBER:
H4b. Is this a TTY number?
Yes
No
H4c. Did someone else help you complete this questionnaire?
Yes Go to question H4d
No Skip to question H5
H4d. Please provide that person’s name and address so we can mail a check for $10.
Name:
Address:
City:
State:
Zip:
H5. Please provide the name, address, and phone number of someone who does not currently live with you who is likely to know where you are if you move.
Name:
Address:
City:
State:
Zip:
Phone:
H5c. What is this person’s email address?
EMAIL ADDRESS:
H5d. What is this person’s relationship to you?
Mother
Adoptive Mother
Stepmother
Foster Mother
Legal Guardian
Sister/Stepsister
Aunt
Grandmother
Father
Adoptive Father
Stepfather
Foster Father
Legal Guardian
Brother/Stepbrother
Uncle
Grandfather
Cousin
Family Friend/Neighbor
Other (Specify)
H6. Please provide the name, address, and phone number of someone else who also would know where you are if you move?
Name:
Address:
City:
State:
Zip:
Phone:
H6c. What is this person’s email address?
EMAIL ADDRESS:
H6d. What is this person’s relationship to you?
Mother
Adoptive Mother
Stepmother
Foster Mother
Legal Guardian
Sister/Stepsister
Aunt
Grandmother
Father
Adoptive Father
Stepfather
Foster Father
Legal Guardian
Brother/Stepbrother
Uncle
Grandfather
Cousin
Family Friend/Neighbor
Other (Specify)
Thank you. You may use the preaddressed and postage paid envelope to return your questionnaire.
| File Type | application/msword |
| File Title | APPENDIX B |
| Author | Linda LeBlanc |
| Last Modified By | DoED User |
| File Modified | 2007-05-23 |
| File Created | 2007-05-23 |