DEI Supplemental Questionnaire for Wisconsin

Office Use Only

WDA ________

PIN # _________

Staff Name:

______________Return to DRC as listed on back

Employee Initiative Information - WI

In our efforts to improve our training and job placement services, we are asking customers to answer a few additional questions related to employment.

This is part of an evaluation of the U.S. Department of Labor's "DEI Initiative."^* The DEI seeks to increase employment opportunities for adults and youth with disabilities while striving to eliminate barriers to their employment.

Privacy Statement: Responses to this data collection are voluntary and will be used only for statistical purposes. Reports prepared for this study will summarize findings across the sample and will not associate responses with a specific firm/establishment/state/district or individual. We will not provide information that identifies you or your firm/establishment/state/district to anyone outside the study team, except as required by law.

I have read and understand the above:

Print Name):                          Sign:                 SSN:                    

1. Do you have a disability? YES NO

If ‘YES’, which of the following most accurately describes your disability?

Physical (Mobility) Sensory (Vision, Hearing) Cognitive (Learning)

Mental Other / Not listed here

2. Are you currently receiving benefits based on a Social Security Disability? YES NO

3. Are you currently a “Ticket to Work” holder? YES NO DON’T KNOW

4. When did you begin employment at your most recent job? If you have never worked before, please enter “99/99/9999” and SKIP questions 5 - 8.

(mm/dd/yyyy)       /       /      

5. If ever employed, what was your most recent job title?

     

6. If ever employed, what was your most recent hourly wage? $       /hour

7. If ever employed, how many hours a week did you work in your most recent job?       hours/week

8. Did your most recent employer offer you: (Please check all that apply)

Health Insurance Working from home Sick Leave Customized Employment

Vacation Job Sharing Flexible Hours On the Job Accommodations None

9. Which of the following things do you think will make it hard for you to get a job?
(Please Check all that apply):

Limited education or training Limited work history/experience

No child care Substance use Limited transportation

Language barrier Ex-Offender Housing/homeless Disability

Job Center Staff – this form MUST be sent to the DRC as listed on the back
within 5 business days of completion.

Public Burden Statement: OMB Control Number 1230-XXXX (Exp. XX/XX/XXXX) The Paperwork Reduction Act of 1995 provides that persons cannot be required to respond to a collection of information unless such collection displays a valid OMB Control Number. Your response is estimated to take about 5 minutes. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Disability Employment Policy, 200 Constitution Ave., Room S-1303, Washington DC, 20210.

* Social Dynamics, LLC is under contract to the U.S. Department of Labor, Office of Disability Employment Policy (ODEP) to conduct an evaluation of the Disability Employment Initiative, which began in October 2010, and is expected to conclude in September 2015. Your responses will be used to prepare a report on the DEI that describes what your state is doing to help you get a job.

If you have any questions about the study, or this form, please contact:
Anne Chamberlain at Social Dynamics, LLC, toll-free: 1-855-990-1105.