EN Report Card Survey

OMB number: 0960-0526

A Consumer Experience Questionnaire
Prepared for:
Social Security’s Ticket to Work Program, Clients of
Service First of Northern California
Stockton, California

Please help our organization make the Ticket to Work program better by answering some questions about
the services you received from your Employment Network, Service First of Northern California.
When done, please seal this questionnaire in the envelope provided and
return to the Ticket to Work Operations Support Manager (MAXIMUS).
Your answers will not influence the services you receive—
the Employment Network’s staff will not see your answers.

Thank you!
Today’s date:
mm

/

dd

/

yyyy

Paperwork Reduction Act Statement
Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. §3507,
as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions
unless we display a valid Office of Management and Budget control number. We estimate that it will take about 10
minutes to complete this survey. You may send comments on our time estimate above to: SSA, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address.
Send the completed questionnaire to:
MAXIMUS Ticket to Work
P.O. Box 1433
Alexandria, VA 22313

For internal use only
© 2009 by uSPEQ. All rights reserved.

Date: 8/26/2009
CES 2.0 Code: ssa_09A

Please indicate if you Strongly Disagree, Disagree, Agree, or Strongly Agree with each of the following
statements below. Mark the circle that best describes your answer about Service First of Northern California,
your Employment Network.

SERVICE RESPONSIVENESS

A.5.

Services are available at times that are OK for me.
I am able to get what I need at the Employment Network, when
I need it.
There are enough staff members available to meet my needs.
I was able to see a staff member at a reasonable time after I
first asked for services.
I am able to get the services I need as soon as I need them.

A.6.

It is easy for me to get to this services location.

A.1.
A.2.
A.3.
A.4.

INFORMED CHOICE
B.1.
B.2.
B.3.
B.4.
B.5.
B.6.
B.7.
B.8.

Staff members make accommodations that meet my individual
needs.
Staff members at the Employment Network pay attention to
what I say.
I have the opportunity to make choices that are important to
me.
Services options were explained in a language I understood.
I agreed with the goals in my plan for services.
Staff members at the Employment Network listen to
beneficiaries.
I was actively involved in deciding my service goals.
Staff members give me clear information on the different
service choices available to help me.

RESPECT
C.1.

Staff members are respectful of my culture.

C.2.

People at the Employment Network respect me as a person.

C.3.
C.4.

Staff members respect my privacy.
Staff members are able to communicate with me in ways that I
understand.

© 2009 by uSPEQ. All rights reserved.

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c
c
c

d
d
d
d
d
d

e
e
e
e
e
e

f
f
f
f
f
f

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c

d

e

f

c

d

e

f

c
c
c
c
c
c

d
d
d
d
d
d

e
e
e
e
e
e

f
f
f
f
f
f

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c

d
d
d
d

e
e
e
e

f
f
f
f

1

Please indicate if you Strongly Disagree, Disagree, Agree, or Strongly Agree with each of the following
statements below. Mark the circle that best describes your answer about Service First of Northern California,
your Employment Network.

PARTICIPATION
D.1.

I am able to deal effectively with everyday life activities.

D.2.

I am able to make choices that are important to me.

D.3.
D.4.

I know where and how to get help I need in the community.
I am generally able to do things I need to do without major
barriers.
As a result of the services I receive, I will be able to find
employment.
I am working at a job that I feel is a good use of my skills and
abilities.
Staff at the Employment Network talked to me about the
assistive technology or equipment I needed.
If I needed assistive technology or equipment to help me, I was
able to get what I needed.

D.5.
D.6.
D.7.
D.8.

OVERALL VALUE
E.1.
E.2.
E.3.
E.4.
E.5.
E.6.

I would recommend the Employment Network to a friend or
family.
The services I receive meet my expectations.
I feel safe at the Employment Network.
The services I receive at the Employment Network make me
better able to do the things I want to do now.
The Employment Network meets the need I came here for.
If I had other choices, I would still come to the Employment
Network.

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c

d
d
d
d

e
e
e
e

f
f
f
f

c

d

e

f

c

d

e

f

c

d

e

f

c

d

e

f

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c
c
c

d
d
d
d
d
d

e
e
e
e
e
e

f
f
f
f
f
f

DEMOGRAPHIC INFORMATION
1.

How long have you been receiving services
here?
c This is my first visit

d
e
f
g
h
i

Less than 3 months
3 – 6 months
7 – 12 months
1 – 2 years
3 – 5 years
More than 5 years

© 2009 by uSPEQ. All rights reserved.

2.
3.

Are you Hispanic/Latino?
c Yes
d No
What is your race (select one or more)?
c White

d
e
f
g

Black, African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific
Islander

2

4.

What is your date of birth?

5.

/ dd / yyyy
mm
What is your gender?
c Male
d
e

6.

7.

Female

Other
What is your primary occupational status?
c Employed

d
e
f
g
h
i
j
k

9.

Supported employment
Self-employment
Non-paid work, such as
voluntary/charity
Student
Homemaker
Retired
Unemployed
Other (specify):

What is the highest level of education you
have completed?
c 8th grade or less

d
e
f
g
h
i
j

8.

10.

In general, would you say your health is:
c Excellent

d
e
f
g

Very good

d
e
f
g
h

Sign language

Good
Fair

Poor
Who answered the questions?
receiving services (no
c Myself—person
one helped)
(someone helped me read
d Myself
and/or write my answers on the form)
else on behalf of the
e Someone
beneficiary
What is your primary means of
communication?
c Spoken language
Finger spelling
Gestures
Communication device
Other (specify):

Some high school, but did not graduate
High school diploma/GED
Some college/technical school
Associate degree
Bachelor’s degree
Master’s degree and above
Other: (specify)

General comments:

© 2009 by uSPEQ. All rights reserved.

3

OMB number: 0960-0526

A Consumer Experience Questionnaire
Prepared for:
Social Security’s Ticket to Work Program, Clients of
Service First of Northern California
Stockton, California

Please help our organization make the Ticket to Work program better by answering some questions about
the services you received from your Employment Network, Service First of Northern California.
When done, please seal this questionnaire in the envelope provided and
return to the Ticket to Work Operations Support Manager (MAXIMUS).
Your answers will not influence the services you receive—
the Employment Network’s staff will not see your answers.

Thank you!
Today’s date:
mm

/

dd

/

yyyy

Paperwork Reduction Act Statement
Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. §3507,
as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions
unless we display a valid Office of Management and Budget control number. We estimate that it will take about 10
minutes to complete this survey. You may send comments on our time estimate above to: SSA, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address.
Send the completed questionnaire to:
MAXIMUS Ticket to Work
P.O. Box 1433
Alexandria, VA 22313

For internal use only
© 2009 by uSPEQ. All rights reserved.

Date: 8/26/2009
CES 2.0 Code: ssa_09B

Please indicate if you Strongly Disagree, Disagree, Agree, or Strongly Agree with each of the following
statements below. Mark the circle that best describes your answer about Service First of Northern California,
your Employment Network.

SERVICE RESPONSIVENESS

A.5.

Services are available at times that are OK for me.
I am able to get what I need at the Employment Network, when
I need it.
There are enough staff members available to meet my needs.
I was able to see a staff member at a reasonable time after I
first asked for services.
I am able to get the services I need as soon as I need them.

A.6.

It is easy for me to get to this services location.

A.1.
A.2.
A.3.
A.4.

INFORMED CHOICE
B.1.
B.2.
B.3.
B.4.
B.5.
B.6.
B.7.
B.8.

Staff members make accommodations that meet my individual
needs.
Staff members at the Employment Network pay attention to
what I say.
I have the opportunity to make choices that are important to
me.
Services options were explained in a language I understood.
I agreed with the goals in my plan for services.
Staff members at the Employment Network listen to
beneficiaries.
I was actively involved in deciding my service goals.
Staff members give me clear information on the different
service choices available to help me.

RESPECT
C.1.

Staff members are respectful of my culture.

C.2.

People at the Employment Network respect me as a person.

C.3.
C.4.

Staff members respect my privacy.
Staff members are able to communicate with me in ways that I
understand.

© 2009 by uSPEQ. All rights reserved.

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c
c
c

d
d
d
d
d
d

e
e
e
e
e
e

f
f
f
f
f
f

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c

d

e

f

c

d

e

f

c
c
c
c
c
c

d
d
d
d
d
d

e
e
e
e
e
e

f
f
f
f
f
f

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c

d
d
d
d

e
e
e
e

f
f
f
f

1

Please indicate if you Strongly Disagree, Disagree, Agree, or Strongly Agree with each of the following
statements below. Mark the circle that best describes your answer about Service First of Northern California,
your Employment Network.

PARTICIPATION
D.1.

I am able to deal effectively with everyday life activities.

D.2.

I am able to make choices that are important to me.

D.3.
D.4.

I know where and how to get help I need in the community.
I am generally able to do things I need to do without major
barriers.
As a result of the services I receive, I will be able to find
employment.
I am working at a job that I feel is a good use of my skills and
abilities.
Staff at the Employment Network talked to me about the
assistive technology or equipment I needed.
If I needed assistive technology or equipment to help me, I was
able to get what I needed.

D.5.
D.6.
D.7.
D.8.

OVERALL VALUE
E.1.
E.2.
E.3.
E.4.
E.5.
E.6.

I would recommend the Employment Network to a friend or
family.
The services I receive meet my expectations.
I feel safe at the Employment Network.
The services I receive at the Employment Network make me
better able to do the things I want to do now.
The Employment Network meets the need I came here for.
If I had other choices, I would still come to the Employment
Network.

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c

d
d
d
d

e
e
e
e

f
f
f
f

c

d

e

f

c

d

e

f

c

d

e

f

c

d

e

f

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c
c
c

d
d
d
d
d
d

e
e
e
e
e
e

f
f
f
f
f
f

DEMOGRAPHIC INFORMATION
1.

How long have you been receiving services
here?
c This is my first visit

d
e
f
g
h
i

Less than 3 months
3 – 6 months
7 – 12 months
1 – 2 years
3 – 5 years
More than 5 years

© 2009 by uSPEQ. All rights reserved.

2.
3.

Are you Hispanic/Latino?
c Yes
d No
What is your race (select one or more)?
c White

d
e
f
g

Black, African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific
Islander

2

4.

What is your date of birth?

5.

/ dd / yyyy
mm
What is your gender?
c Male
d
e

6.

7.

Female

Other
What is your primary occupational status?
c Employed

d
e
f
g
h
i
j
k

9.

Supported employment
Self-employment
Non-paid work, such as
voluntary/charity
Student
Homemaker
Retired
Unemployed
Other (specify):

What is the highest level of education you
have completed?
c 8th grade or less

d
e
f
g
h
i
j

8.

10.

In general, would you say your health is:
c Excellent

d
e
f
g

Very good

d
e
f
g
h

Sign language

Good
Fair

Poor
Who answered the questions?
receiving services (no
c Myself—person
one helped)
(someone helped me read
d Myself
and/or write my answers on the form)
else on behalf of the
e Someone
beneficiary
What is your primary means of
communication?
c Spoken language
Finger spelling
Gestures
Communication device
Other (specify):

Some high school, but did not graduate
High school diploma/GED
Some college/technical school
Associate degree
Bachelor’s degree
Master’s degree and above
Other: (specify)

General comments:

© 2009 by uSPEQ. All rights reserved.

3

OMB number: 0960-0526

A Consumer Experience Questionnaire
Prepared for:
Social Security’s Ticket to Work Program, Clients of
Service First of Northern California
Stockton, California

Please help our organization make the Ticket to Work program better by answering some questions about
the services you received from your Employment Network, Service First of Northern California.
When done, please seal this questionnaire in the envelope provided and
return to the Ticket to Work Operations Support Manager (MAXIMUS).
Your answers will not influence the services you receive—
the Employment Network’s staff will not see your answers.

Thank you!
Today’s date:
mm

/

dd

/

yyyy

Paperwork Reduction Act Statement
Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. §3507,
as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions
unless we display a valid Office of Management and Budget control number. We estimate that it will take about 10
minutes to complete this survey. You may send comments on our time estimate above to: SSA, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address.
Send the completed questionnaire to:
MAXIMUS Ticket to Work
P.O. Box 1433
Alexandria, VA 22313

For internal use only
© 2009 by uSPEQ. All rights reserved.

Date: 8/26/2009
CES 2.0 Code: ssa_09C

Please indicate if you Strongly Disagree, Disagree, Agree, or Strongly Agree with each of the following
statements below. Mark the circle that best describes your answer about Service First of Northern California,
your Employment Network.

SERVICE RESPONSIVENESS

A.5.

Services are available at times that are OK for me.
I am able to get what I need at the Employment Network, when
I need it.
There are enough staff members available to meet my needs.
I was able to see a staff member at a reasonable time after I
first asked for services.
I am able to get the services I need as soon as I need them.

A.6.

It is easy for me to get to this services location.

A.1.
A.2.
A.3.
A.4.

INFORMED CHOICE
B.1.
B.2.
B.3.
B.4.
B.5.
B.6.
B.7.
B.8.

Staff members make accommodations that meet my individual
needs.
Staff members at the Employment Network pay attention to
what I say.
I have the opportunity to make choices that are important to
me.
Services options were explained in a language I understood.
I agreed with the goals in my plan for services.
Staff members at the Employment Network listen to
beneficiaries.
I was actively involved in deciding my service goals.
Staff members give me clear information on the different
service choices available to help me.

RESPECT
C.1.

Staff members are respectful of my culture.

C.2.

People at the Employment Network respect me as a person.

C.3.
C.4.

Staff members respect my privacy.
Staff members are able to communicate with me in ways that I
understand.

© 2009 by uSPEQ. All rights reserved.

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c
c
c

d
d
d
d
d
d

e
e
e
e
e
e

f
f
f
f
f
f

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c

d

e

f

c

d

e

f

c
c
c
c
c
c

d
d
d
d
d
d

e
e
e
e
e
e

f
f
f
f
f
f

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c

d
d
d
d

e
e
e
e

f
f
f
f

1

Please indicate if you Strongly Disagree, Disagree, Agree, or Strongly Agree with each of the following
statements below. Mark the circle that best describes your answer about Service First of Northern California,
your Employment Network.

PARTICIPATION
D.1.

I am able to deal effectively with everyday life activities.

D.2.

I am able to make choices that are important to me.

D.3.
D.4.

I know where and how to get help I need in the community.
I am generally able to do things I need to do without major
barriers.
As a result of the services I receive, I will be able to find
employment.
I am working at a job that I feel is a good use of my skills and
abilities.
Staff at the Employment Network talked to me about the
assistive technology or equipment I needed.
If I needed assistive technology or equipment to help me, I was
able to get what I needed.

D.5.
D.6.
D.7.
D.8.

OVERALL VALUE
E.1.
E.2.
E.3.
E.4.
E.5.
E.6.

I would recommend the Employment Network to a friend or
family.
The services I receive meet my expectations.
I feel safe at the Employment Network.
The services I receive at the Employment Network make me
better able to do the things I want to do now.
The Employment Network meets the need I came here for.
If I had other choices, I would still come to the Employment
Network.

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c

d
d
d
d

e
e
e
e

f
f
f
f

c

d

e

f

c

d

e

f

c

d

e

f

c

d

e

f

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c
c
c

d
d
d
d
d
d

e
e
e
e
e
e

f
f
f
f
f
f

DEMOGRAPHIC INFORMATION
1.

How long have you been receiving services
here?
c This is my first visit

d
e
f
g
h
i

Less than 3 months
3 – 6 months
7 – 12 months
1 – 2 years
3 – 5 years
More than 5 years

© 2009 by uSPEQ. All rights reserved.

2.
3.

Are you Hispanic/Latino?
c Yes
d No
What is your race (select one or more)?
c White

d
e
f
g

Black, African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific
Islander

2

4.

What is your date of birth?

5.

/ dd / yyyy
mm
What is your gender?
c Male
d
e

6.

7.

Female

Other
What is your primary occupational status?
c Employed

d
e
f
g
h
i
j
k

9.

Supported employment
Self-employment
Non-paid work, such as
voluntary/charity
Student
Homemaker
Retired
Unemployed
Other (specify):

What is the highest level of education you
have completed?
c 8th grade or less

d
e
f
g
h
i
j

8.

10.

In general, would you say your health is:
c Excellent

d
e
f
g

Very good

d
e
f
g
h

Sign language

Good
Fair

Poor
Who answered the questions?
receiving services (no
c Myself—person
one helped)
(someone helped me read
d Myself
and/or write my answers on the form)
else on behalf of the
e Someone
beneficiary
What is your primary means of
communication?
c Spoken language
Finger spelling
Gestures
Communication device
Other (specify):

Some high school, but did not graduate
High school diploma/GED
Some college/technical school
Associate degree
Bachelor’s degree
Master’s degree and above
Other: (specify)

General comments:

© 2009 by uSPEQ. All rights reserved.

3

OMB number: 0960-0526

A Consumer Experience Questionnaire
Prepared for:
Social Security’s Ticket to Work Program, Clients of
Service First of Northern California
Stockton, California

Please help our organization make the Ticket to Work program better by answering some questions about
the services you received from your Employment Network, Service First of Northern California.
When done, please seal this questionnaire in the envelope provided and
return to the Ticket to Work Operations Support Manager (MAXIMUS).
Your answers will not influence the services you receive—
the Employment Network’s staff will not see your answers.

Thank you!
Today’s date:
mm

/

dd

/

yyyy

Paperwork Reduction Act Statement
Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. §3507,
as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions
unless we display a valid Office of Management and Budget control number. We estimate that it will take about 10
minutes to complete this survey. You may send comments on our time estimate above to: SSA, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address.
Send the completed questionnaire to:
MAXIMUS Ticket to Work
P.O. Box 1433
Alexandria, VA 22313

For internal use only
© 2009 by uSPEQ. All rights reserved.

Date: 8/26/2009
CES 2.0 Code: ssa_09

Please indicate if you Strongly Disagree, Disagree, Agree, or Strongly Agree with each of the following
statements below. Mark the circle that best describes your answer about Service First of Northern California,
your Employment Network.

SERVICE RESPONSIVENESS

A.5.

Services are available at times that are OK for me.
I am able to get what I need at the Employment Network, when
I need it.
There are enough staff members available to meet my needs.
I was able to see a staff member at a reasonable time after I
first asked for services.
I am able to get the services I need as soon as I need them.

A.6.

It is easy for me to get to this services location.

A.1.
A.2.
A.3.
A.4.

INFORMED CHOICE
B.1.
B.2.
B.3.
B.4.
B.5.
B.6.
B.7.
B.8.

Staff members make accommodations that meet my individual
needs.
Staff members at the Employment Network pay attention to
what I say.
I have the opportunity to make choices that are important to
me.
Services options were explained in a language I understood.
I agreed with the goals in my plan for services.
Staff members at the Employment Network listen to
beneficiaries.
I was actively involved in deciding my service goals.
Staff members give me clear information on the different
service choices available to help me.

RESPECT
C.1.

Staff members are respectful of my culture.

C.2.

People at the Employment Network respect me as a person.

C.3.
C.4.

Staff members respect my privacy.
Staff members are able to communicate with me in ways that I
understand.

© 2009 by uSPEQ. All rights reserved.

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c
c
c

d
d
d
d
d
d

e
e
e
e
e
e

f
f
f
f
f
f

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c

d

e

f

c

d

e

f

c
c
c
c
c
c

d
d
d
d
d
d

e
e
e
e
e
e

f
f
f
f
f
f

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c

d
d
d
d

e
e
e
e

f
f
f
f

1

Please indicate if you Strongly Disagree, Disagree, Agree, or Strongly Agree with each of the following
statements below. Mark the circle that best describes your answer about Service First of Northern California,
your Employment Network.

PARTICIPATION
D.1.

I am able to deal effectively with everyday life activities.

D.2.

I am able to make choices that are important to me.

D.3.
D.4.

I know where and how to get help I need in the community.
I am generally able to do things I need to do without major
barriers.
As a result of the services I receive, I will be able to find
employment.
I am working at a job that I feel is a good use of my skills and
abilities.
Staff at the Employment Network talked to me about the
assistive technology or equipment I needed.
If I needed assistive technology or equipment to help me, I was
able to get what I needed.

D.5.
D.6.
D.7.
D.8.

OVERALL VALUE
E.1.
E.2.
E.3.
E.4.
E.5.
E.6.

I would recommend the Employment Network to a friend or
family.
The services I receive meet my expectations.
I feel safe at the Employment Network.
The services I receive at the Employment Network make me
better able to do the things I want to do now.
The Employment Network meets the need I came here for.
If I had other choices, I would still come to the Employment
Network.

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c

d
d
d
d

e
e
e
e

f
f
f
f

c

d

e

f

c

d

e

f

c

d

e

f

c

d

e

f

Strongly
Disagree

Disagree

Agree

Strongly
Agree

c
c
c
c
c
c

d
d
d
d
d
d

e
e
e
e
e
e

f
f
f
f
f
f

DEMOGRAPHIC INFORMATION
1.

How long have you been receiving services
here?
c This is my first visit

d
e
f
g
h
i

Less than 3 months
3 – 6 months
7 – 12 months
1 – 2 years
3 – 5 years
More than 5 years

© 2009 by uSPEQ. All rights reserved.

2.
3.

Are you Hispanic/Latino?
c Yes
d No
What is your race (select one or more)?
c White

d
e
f
g

Black, African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific
Islander

2

4.

What is your date of birth?

5.

/ dd / yyyy
mm
What is your gender?
c Male
d
e

6.

7.

Female

Other
What is your primary occupational status?
c Employed

d
e
f
g
h
i
j
k

9.

Supported employment
Self-employment
Non-paid work, such as
voluntary/charity
Student
Homemaker
Retired
Unemployed
Other (specify):

What is the highest level of education you
have completed?
c 8th grade or less

d
e
f
g
h
i
j

8.

10.

In general, would you say your health is:
c Excellent

d
e
f
g

Very good

d
e
f
g
h

Sign language

Good
Fair

Poor
Who answered the questions?
receiving services (no
c Myself—person
one helped)
(someone helped me read
d Myself
and/or write my answers on the form)
else on behalf of the
e Someone
beneficiary
What is your primary means of
communication?
c Spoken language
Finger spelling
Gestures
Communication device
Other (specify):

Some high school, but did not graduate
High school diploma/GED
Some college/technical school
Associate degree
Bachelor’s degree
Master’s degree and above
Other: (specify)

General comments:

© 2009 by uSPEQ. All rights reserved.

3