sample data collection form

A Sample Data Collection Form for Covered Entrants at Physical Locations

1. Did you serve on active duty in the U.S. military and receive a discharge that was under conditions other than dishonorable?

_____ Yes (You are eligible for priority of service; please skip to Item 4.)

_____ No (Go to Item 2.)

2. Are you the spouse of a veteran who: a) has a total, service-connected disability; OR b) has for more than 90 days been missing in action, captured by a hostile force, or forcibly detained by a foreign government?

_____ Yes (You are eligible for priority of service; please skip to Item 4.)

_____ No (Go to Item 3.)

3. Are you the widow of a veteran who: a) died of a service-connected disability; OR b) died of any cause after being determined to have a total, service-connected disability?

_____ Yes (You are eligible for priority of service; please skip to Item 4.)

_____ No (You are not eligible for priority of service; thank you for your time!)

4. Point of Entry Date: ____ ____ ____

Month Day Year

5. Name: _______________________ _________________________

Last First

Please Note: Your cooperation in answering the questions that follow is requested but not required; a refusal to provide this information will not affect your eligibility for services or your eligibility for priority of service. (This information is requested by the Department of Labor (DOL) for its use in monitoring equal opportunity requirements, and for the use of DOL and the organization responsible for operating this program to improve outreach activities to members of diverse populations.)

6. Date of Birth: ____ ____ ____

Month Day Year

7. Sex/Gender

_____ Male

_____ Female

8. Do you consider yourself to have a disability, that is, a physical or mental impairment that limits one or more of your major life activities?

_____ Yes

_____ No

9. Do you consider yourself to belong to a Latino or Hispanic ethnic group?

_____ Hispanic or Latino

_____ Not Hispanic or Latino

10. Please indicate which of the racial groups below you consider yourself to be a member of. If you consider yourself to be a member of more than one group, please select all the groups that apply.

_____ American Indian or Alaska Native

_____ Asian

_____ Black or African American

_____ Native Hawaiian or other Pacific Islander

_____ White