Acess to Telework Programs Data Collection Instrument an

Access to Telework Programs

Data Collection Instrument and Instructions

One Year Follow-up Data

At the one-year anniversary of the loan, use this survey form to ask follow-up questions to the Direct Users who have had their loan for one year. The survey will allow you to report on whether Direct Users’ primary employment goals at the time of loan closings were achieved one year later as a result of a Telework loan.

Telework Programs may collect this follow-up data in a manner that best meets their needs. The data from the Direct Users may be collected in person, via phone, via mail, or online. Regardless of the method of data collection, programs should collect the data from the Direct User as near as possible to the 12-month anniversary of the loan’s closing. To produce valid data, you should try to obtain as high a response rate as possible.

To be completed by Telework program staff:

Employment status at time of application:

____ Unemployed ____ Self-employed

____ Employed ____ Employed and Self-employed

Primary employment goal at time of application was to:

____ Become newly employed in telework for an employer.

____ Become newly self-employed.

____ Change to teleworking job for an employer.

____ Change to self-employment job

____ Expand existing business.

____ Other, brief description:

Please answer the following questions about the loan that you received from (insert name of Telework Loan Program).

1. Since receiving your Telework loan one year ago, have you achieved your primary employment goal? (Please mark only one answer.)

YES, I achieved my primary employment goal:

____ I have become newly employed in telework for an employer. (I did not have a job and now I do have a job.)

____ I have become newly self-employed. (I did not have a job and now I work for myself.)

____ I changed to a teleworking job for an employer. (I had a job but I changed

job/kind of work.)

____ I changed to a self-employment job. (I had a job but now I work for myself.)

____ I expanded my business.

____ I had another goal. Brief description:

_____ NO, but I changed my employment goal and achieved it.

_____ NO, I did not achieve my primary employment goal.

2. If you achieved your employment goal, please answer the following:

Did your wages/salary increase? ____ YES ____ NO

Were you able to maintain your employment? ____ YES ____ NO

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 form is estimated to average 10 minutes per response, including the time to review 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, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Office of the Chief Financial Officer, U.S. Department of Education, 600 Independence Avenue, SW, Washington, D.C. 20202-4248.