Survey JAN Self-Individual Interview

SELF/INDIVIDUAL OMB Contol no. 1225-0059

Changes marked in Red below

Section II. Outreach

1. How did you know to contact the Job Accommodation Network

(ALL THAT APPLY); [Interviewers FIELD CODE into the following categories]

a. Used JAN service before

b. Previous user of JAN service (specify if another employer)

c. JAN Website

d. Other website (not JAN website)

e. Internet search

f. Referral from:

Organization (list) ________________________

Government Agency (list) __________________

Company

DOL Call Center

EARN

JAN self employment

g. Friend/co-worker/word of mouth

h. Personal contact with JAN staff member

i. Rehabilitation professional

j. Medical professional

k. Educational institution

l. Union

m. Legal professional

n. Newspaper/magazine/book/professional journal article

o. Television (report or advertisement)

p. Listed in a directory

q. I&R Service

r. Conference

s. JAN Publication or Brochure

t. JAN presentation

u. Used JAN Self-employment service before

v. Previous user of JAN Self-employment service

w. JAN Self-employment Website

x. JAN Self-employment Publication or Brochure

y. Other (please specify): _____________________________________________________

Section III. ACCOMMODATION OUTCOME

"The following questions explore the outcomes of your consultation with JAN."

ASK ONLY IF WORK ACCOMMODATION INFORMATION WAS PROVIDED

Else go to IIIE for EDUCATION ACCOMMODATION

W1. Was the accommodation you discussed with the JAN consultant about

a. applying for a job

b. a job that you just started or are going to start

c. keeping your current job

d. being promoted

e. some other situation? __________________________________________________

DATA ENTRY ONLY (INTERVIEWER: CIRCLE IF APPLICABLE)

f. involving more than one employee

W3. How many years have you been with the company? ____ . _

W2. Removed

W4. What is the wage (by hour or annually) for your job

a. by hour _______ and how many hours did you work on average per week ___________

b. Annually_______________

IF DK, THEN,

Does this job usually pay

a. less than $10,000 per year

b. $10,000 - $20,000

c. $20,001 - $50,000

d. $50,001 - $100,000

e. More than $100,000

[If queried, interviewer may say "Because JAN is a service funded by the federal government, it is important for JAN to establish that they reach a wide range of individuals."]

W5. What is your highest level of education

1. Did not complete high school

2. High school certificate (not high school diploma)

3. High school diploma or GED (code this if participant says "graduated from high school")

d. Associates Degree (2 year degree)

e. Graduated from college (4 year degree)

f. Degree from graduate/professional school (e.g., MA, MBA, PhD, MD, JD)

g. DK

h. RF

W6. What is your gender? [Interviewers ask even if it seems evident]

[If queried, interviewer may say "Because JAN is a service funded by the federal government, it is important for JAN to establish that they reach a wide range of individuals.]

a. Male

b. Female

c. DK

d. RF

W7. What is your race or ethnicity? (CHOOSE ALL THAT APPLY?)

Race

a. American Indian or Alaska Native

b. Asian

c. Black or African American

d. Native Hawaiian or Other Pacific Islander

e. White

f. Other

Ethnicity

g. Hispanic or Latino

h. Not Hispanic or Latino

i. DK j. RF

W8. What is your age?

a. less than 18 b. 18 – 25 c. 26 - 35

d. 36 – 45 e. 46 – 55 f. 56 - 65

g. 66 and over h. DK i. RF

10a. Who makes the decision whether the company will provide an accommodation? (mark all that apply)

1. Human Resources or Personnel department

b. Legal department

c. Managers

d. Employee's (your) supervisor

e. Other: _______________________________________

W10. After your interaction with JAN, was an accommodation made? (Choose one of a-h)

a. Yes or No

2. Implementation Pending (DECISION TO ACCOMMODATE MADE, BUT IMPLEMENTATION PENDING (EXPLAIN/Why?) __________

c. Decision pending (explain/Why?) _____________________________________________

d. No (Please explain why an accommodation was not made.) [Interviewer to query for reason for rejecting accommodation.] ____________________________

e. other (e.g., employee resigned) ____________________________________________

Please tell me briefly about that. _____________________________________

f. DK g. RF h. N/A

DATA ENTRY ONLY – IF ACCOMMODATION WAS NOT IMPLEMENTED, WHAT WAS THE REASON? (INTERVIEWER: CIRCLE REASON)

1. Implementation pending (if 10 = b)

2. Decision pending (if 10 = c)

3. Determined not required by ADA/other law (rejected)

4. Determined not possible to accommodate (rejected)

5. Determined not needed by employee (other)

6. Accommodation implemented before contacting JAN (other)

7. Accommodation rejected before contacting JAN (other)

8. Other reason (for rejection or other)

11. Did this accommodation solution that (was made, is pending implementation, the decision is pending on, was rejected) include: [Repeat as necessary as preface to each item in table.]

	Yes		No	Rejected	Pending	DK	RF	Other
	Made	Waiting
Buying a product or piece of equipment (like software, or a tool)? What specific products or pieces of equipment?	Has that accommodation been made?	Are you still waiting on implementation?
Modifying a product or piece of equipment (like software, or a tool) Please describe how the product or equipment was or will be modified?
Modifying the worksite (like a ramp, lighting or mirrors) Please describe the modifications to the worksite
Changes to a work schedule ( such as flex time, shift change, part time) Please describe the changes to the work schedule [Light duty = work schedule change if same job, reassignment of changed job title]
Moving the employee to another job (or reassignment) What type of work was the employee doing before reassignment & what type of work is or will he be doing after
Changes in workplace policy What workplace policies were modified?
Formal or Company Education of co-workers Please describe how the company was/is going to educate co-workers
	Yes		No	Rejected	Pending	DK	RF	Other
	Made	Waiting
h. Providing an interpreter, reader, job coach or personal attendant services? Which services were provided
i. Providing information in an alternative format (e.g., large print, taped text, Braille, etc.) What alternative formats were provided?
j. Working from home or telework What arrangements were made (# of hours in # hours/wk)
k. Are there accommodation solutions that we have not talked about? IF YES, Please specify
DATA ENTRY ONLY (INTERVIEWER: RECORD IF APPLICABLE) l. Moved the employee to another location

[IF ANY PARTS OF WQ11= MADE, Continue, else go to Question W14]

W12. On a scale of 1 – 5, how effective was the accommodation, with 1 being (not effective at all) and 5 being (extremely effective)?

1 2 3 4 5 8 = DK 9 = RF

not effective at all extremely effective

W13. Please describe why the accommodation was or was not effective?

[If any parts of WQ11 = MADE or PENDING IMPLEMENTATION, Continue;

Else Skip to Section III.E]

W14. Approximately how much did the accommodation cost (or is expected to cost)?

[For Each Cost Designate Whether Actual or Predicted Cost]

a. one-time cost _$____________OR

b. annually _$_____________

DK = 888,888 RF = 999,999

[IF QW14 = $ 0, THEN SKIP TO Section III.E]

W15. Who helped (or is expected to) pay for the accommodation? (All the Apply)

a. Employer

b. Employee

c. Rehabilitation Services

d. Insurance Company

e. Other

If "Employer", ask:

15a. What was the source of funding for this accommodation?

a. Departmental funds

b. Human Resources funds

c. Company general funds

d. Other: ___________________________________________

DATA ENTRY ONLY (INTERVIEWER: CIRCLE IF APPLICABLE)

e. Specific accommodation-related funds

15b. Who has the authority to authorize expenditure for accommodations?

a. Local managers/supervisors

b. Human Resources representatives

c. Corporate/General Management

d. Other: ___________________________________________

[IF ONLY ONE ANSWER TO 15, SKIP TO Section III.E]

W16. How much did (or will) each pay? (PERCENT OR $ AMOUNT)

a. Employer

b. Employee

c. Rehabilitation Services

d. Insurance Company

e. Other

IIIE. Education Accommodation

Ask only if Purpose of Call = Education Accommodation, Else skip to section IV.

E1. Was the accommodation you discussed with JAN about accommodating you for

a. Elementary/Middle school K-8

b. High School 9-12

c. Technical Trade School

d. Higher Education - College or University level

e. Other (Please explain: ________________________________________________)

E2. Are you

a. Currently enrolled in a degree or certification program

b. Applying for a program

c. Other (Please explain: ________________________________________________)

E6. What is your gender?

[Interviewers ask even if it seems evident]

[If queried, interviewer may say "Because JAN is a service funded by the federal government, it is important for JAN to establish that they reach a wide range of individuals."]

a. Male

b. Female

c. DK

d. RF

E7. What is your race or ethnicity? (CHOOSE ALL THAT APPLY?)

Race

a. American Indian or Alaska Native

b. Asian

c. Black or African American

d. Native Hawaiian or Other Pacific Islander

e. White

f. Other

Ethnicity

g. Hispanic or Latino

h. Not Hispanic or Latino

i. DK

j. RF

E8. What is your age?

a. less than 18 b. 18 – 25 c. 26 - 35

d. 36 – 45 e. 46 – 55 f. 56 - 65

g. 66 and over h. DK i. RF

E10. After your interaction with JAN, was an accommodation made? (Choose one of a-h)

a. Yes

b. Implementation Pending (DECISION TO ACCOMMODATE MADE, BUT IMPLEMENTATION PENDING (EXPLAIN/Why?) __________

c. Decision pending (explain/Why?) _____________________________________________

d. No (Please explain why an accommodation was not made. - INCLUDE REASON FOR REJECTING ACCOM.) ____________________________

e. other (e.g., employee resigned) explain Please tell me briefly about that. _____________________________________

f. DK

g. RF

h. N/A

DATA ENTRY ONLY – IF ACCOMMODATION WAS NOT IMPLEMENTED, WHAT WAS THE REASON? (INTERVIEWER: CIRCLE REASON)

9. Implementation pending (if 10 = b)

10. Decision pending (if 10 = c)

11. Determined not required by ADA/other law (rejected)

12. Determined not possible to accommodate (rejected)

13. Determined not needed by employee (other)

14. Accommodation implemented before contacting JAN (other)

15. Accommodation rejected before contacting JAN (other)

16. Other reason (for rejection or other)

E11. Did this accommodation solution include: [Repeat as necessary as preface to each item in table.]

	Yes		No	Rejected	Pending	DK	RF	Other
	Made	Waiting
a. Buying a product or piece of equipment (like software, or a tool)? What specific products or pieces of equipment?	Has that accommodation been made?	Are you still waiting on implementation?
b. Modifying a product or piece of equipment (like software, or a tool) Please describe how the product or equipment was or will be modified?
	Yes		No	Rejected	Pending	DK	RF	Other
	Made	Waiting
c. Modifying the facility (e.g., ramps, bathroom modification, parking) Please describe the modifications of the facility
d. Changes to student schedule Please describe the changes to the student schedule
e. Changes to course or school policy (e.g., allow service animal, increase time to take exam) What was the change to course or school policy
f. Providing interpreter, reader, scribe, or other service? Which services were provided?
g. Providing information in an alternative format (e.g., large print, taped text, Braille, etc.) What alternative formats were provided?
h. Are there accommodation solutions that we have not talked about? If YES, please specify.
DATA ENTRY ONLY (INTERVIEWER: RECORD IF APPLICABLE) l. Moved the employee to another location

[IF ANY PARTS OF QE11 = MADE , Continue, Else SKIP TO Question E14]

E12. On a scale of 1 – 5, how effective was the accommodation, with 1 being (not effective at all) and 5 being (extremely effective)?

1 2 3 4 5 8 = DK 9 = RF

not effective at all extremely effective

E13. Please describe why the accommodation was or was not effective?

[If Any of QE11 = MADE OR PENDING IMPLEMENTATION, Continue

ELSE, Skip to Section IV]

E14. Approximately how much did the accommodation cost or is it expected to cost?

a. one-time cost _$____________OR

b. annually _$_____________

DK = 888,888 RF = 999,999

[IF Q14 = 0, THEN SKIP TO NEXT SECTION]

E15. Who helped pay for or will help pay for the accommodation? (All that Apply)

a. School or Educational Institution

b. Rehabilitation Services

c. Insurance Company

d. Student or Family Member

e. Other: ________________________________________

[If ONLY ONE ANSWER, SKIP TO NEXT SECTION]

E16. How much did or will each pay? (PERCENT OR $ AMOUNT)

a. School or Educational Institution

b. Rehabilitation Services

c. Insurance Company

d. Student or Family Member

e. Other: _______________________________________

Section IV. Legislative Outcomes

ASK ONLY IF Purpose of Call = WORK LEGISLATION, EDUCATION LEGISLATION, or PUBLIC ACCOMMODATION;

Else GO To Section V.

Legislation Information:

The next few questions ask about how you used the information about ADA or other laws that you received from JAN.

1. Did the information help you to understand the ADA or another law?

a. YES

2. NO

3. DK

4. RF

Word change in question 2. (last word in sentence - decision changed to change)

2. Was the information used to argue for or make a policy change?

Explanation of policy decision removed.

a. YES

2. NO (SKIP TO Next Section)

3. DK (SKIP TO Next Section)

4. RF (SKIP TO Next Section)

3. What was the outcome of that policy decision?

a. the policy was changed

b. the policy was not changed

c. the decision about whether to change the policy is still pending

d. other. (Explain) _____________________________________

i. DK

j. RF

DATA ENTRY ONLY (INTERVIEWER: CIRCLE ONE)

1 – Policy changed (if 3 = a)

2 – Policy not changed (if 3 = b)

3 – Decision still pending (if 3 = c)

4 – Confirm/validate/interpret existing policy (other)

5 – Accommodation decision made (other) –

6 – Other (anything else identified in “other”)

Section V. JAN Web site

A. User Satisfaction - Ease of Use

1. Have you visited the JAN website within the last year? [If queried, "JAN website is at: http://www.jan.wvu.edu/]

1. YES

2. NO [SKIP TO Section VI.]

3. DK [SKIP TO Section VI.]

4. RF [SKIP TO Section VI.]

2. On a scale of 1 to 5 with 1 being difficult and 5 being easy, how was the website to navigate?

1 2 3 4 5 8 = DK 9 = RF

(difficult) (easy)

[If response = "1", query "So, the website was difficult for you to navigate?"]

3. On the same scale, how was it for you to obtain the information that you needed from the website?

1 2 3 4 5 8 = DK 9 = RF

(difficult) (easy)

[If response = "1", query "So, it was difficult for you to get the information that you needed from the website?"]

4. What did you hope to find on the Website? ________________________________________

5. Did you find it? Yes ____ No _____

IF NO, Please tell me more about that.___________________________________

Section VI. General User Satisfaction

The last few questions are more general. Please tell me...

1. On a scale from 1 to 5, with 1 being difficult to use and 5 as easy, how easy or difficult was it to contact JAN?

1 2 3 4 5 7. NA 8. DK 9. RF

(difficult) (easy)

[If response = "1", query "So, it was difficult for you to contact JAN?"]

2. On a scale of 1 to 5 with 1 being “not courteously” and 5 being “courteously,” how were you treated by the receptionist at JAN?

1 2 3 4 5 8 = DK 9 = RF

(not courteously) (courteously)

[If response = "1", query " "So, the JAN receptionists were not courteous?"]

Spontaneous Comments: ____________________________________________________________

3. On that same scale, how were you treated by the consultant at JAN?

1 2 3 4 5 8 = DK 9 = RF

(not courteously) (courteously)

[If response = "1", query "So, the JAN consultant was not courteous?"

Spontaneous Comments: ____________________________________________________________

4. On a scale from 1to 5, with 1 being "not understand" and 5 being "understood" , how well did the consultant understand your needs?

1 2 3 4 5 8 = DK 9 = RF

(not understand) (understood)

[If response = "1", query "So, the consultant did not understand your needs?"]

Spontaneous Comments: ____________________________________________________________

5. On a scale from 1 to 5, with 1 being “did not meet my needs at all” to 5 “met my needs exceptionally well”, how well did the information that you received meet your needs?

1 2 3 4 5 8. DK 9. RF

(not at all) (exceptionally well)

[If response = "1", query "So, the information you received did not meet your needs at all?]

6. How could the services you received have better met your needs?

7. Where would you get the type of information that JAN provides if JAN did not exist?

8. Would you use the service again, if you needed information?

a. Yes b. No 8 = DK 9 = RF

9. Have you referred other people to JAN?

a. Yes

b. No

10. On a scale from 1 to 5, with 1 being "very unlikely to refer" and 5 being "very likely to refer", how likely would you be to refer other people to JAN?

1 2 3 4 5 8. DK 9. RF

Very unlikely Very likely

11. We would appreciate any comments or suggestions that you may have about JAN.

Thank you for your participation.

Self 14