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pdfOMB Control No. 1225-0059
Expiration Date 11/30/2020
JAN Employer Survey
Start of Block: Default Question Block
Q1 What was your reason for contacting the Job Accommodation Network (JAN)?
o An accommodation (1)
o To understand the ADA or any other disability law or policy (2)
o Both (3)
Q2 How did you know to contact JAN?
o Used JAN service before/Previous user of JAN service (1)
o Internet search (2)
o Referral. Please explain. (3) ______________________________________________
o Other. Please explain. (4) ________________________________________________
o Do not know (5)
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. Public reporting burden for this collection of information is estimated to average
15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary.
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 the Chief Information Officer, Attention: Departmental Clearance
Officer, 200 Constitution Avenue, N.W., Room N-1301, Washington, DC 20210 or email [email protected] and
reference the OMB Control Number 1225-0059. Note: Please do not return the completed survey to this address.
Page 1 of 30
Q3 Was the accommodation you discussed with the JAN consultant about:
o Retaining an employee (keeping employee in current position) (8)
o A job applicant (application, interview) (1)
o Hiring a new employee (already have a job offer, maybe just started or hasn't started
yet) (2)
o Promoting a current employee (4)
o General issue involving more than one employee (5)
o Other. Please explain. (6) ________________________________________________
o Do not know (7)
Page Break
Page 2 of 30
Q6 What is this employee's highest level of education?
o Did not complete high school (1)
o High school certificate (not high school diploma) (2)
o High school diploma or GED (3)
o Associates degree (2 year degree) (4)
o Graduated from college (4 year degree) (5)
o Degree from graduate/professional school (e.g., MA, MBA, PhD, MD, JD) (6)
o Do not know (7)
Q7 What is the employee's gender?
o Male (1)
o Female (2)
o Transgender (3)
o Do not know (4)
Page 3 of 30
Q8 What is the employee's race? (Choose all that apply)
▢
▢
▢
▢
▢
▢
▢
American Indian or Alaska Native (1)
Asian (2)
Black or African American (3)
Native Hawaiian or Other Pacific Islander (4)
White (5)
Other (6)
Do not know (9)
Q53 What is the employee's ethnicity? (Choose all that apply)
▢
▢
▢
Hispanic or Latino (1)
Not Hispanic or Latino (2)
Do not know (3)
Page 4 of 30
Q9 What is the employee's age?
o Less than 17 (1)
o 18-24 (2)
o 25-29 (3)
o 30-39 (4)
o 40-49 (5)
o 50-59 (6)
o 60-65 (7)
o 66 and over (8)
o Do not know (9)
Page Break
Page 5 of 30
Q4 How many years has your employee been with your company?
________________________________________________________________
Q5 What is the wage for this employee's job? (pick one)
o By hour ($) (1) ________________________________________________
o Annually ($) (2) ________________________________________________
o Do not know (3)
Page Break
Page 6 of 30
Q10 Approximately how many employees are in the company? (Number)
________________________________________________________________
Q11 Of these employees how many are individuals that your company considers to have a
disability? (Number)
________________________________________________________________
Page Break
Page 7 of 30
Q12 Who makes the decision whether the company will provide an accommodation? (Mark all
that apply)
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▢
▢
▢
▢
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Human Resources/Employee Relations or Personnel Department (1)
Legal Department (2)
Managers (3)
Employee's Supervisor (4)
Diversity and Inclusion Office (5)
Other. Please explain. (6) ________________________________________________
Q13 After your interaction with JAN, was an accommodation made? (Choose all that apply)
o Yes (1)
o Implementation pending (decision to accommodate made, but implementation pending).
Please explain. (2) ________________________________________________
o Decision pending. Please explain. (7)
________________________________________________
o No. Please explain. (3) ________________________________________________
o Other (e.g., employee resigned). Please explain. (4)
________________________________________________
o Do not know (5)
o Not applicable (6)
Skip To: Q29 If After your interaction with JAN, was an accommodation made? (Choose all that apply) =
Not applicable
Page 8 of 30
Page 9 of 30
Q54 What did the accommodation solution include?
Page 10 of 30
Accommodati
on made (1)
Accommodati
on
implementatio
n is pending
(2)
Decision
about the
accommodati
on is pending
(3)
Accommodati
on was
rejected (4)
Not
applicabl
e (5)
Buying a
product or
piece of
equipment
(like software
or tool)? What
specific
products or
pieces of
equipment? (1)
o
o
o
o
o
Modifying a
product or
piece of
equipment
(like software
or a tool)?
Please
describe how
the product or
equipment was
or will be
modified. (2)
o
o
o
o
o
Modifying the
worksite (like a
ramp, lighting,
or mirrors)?
Please
describe the
modification to
the worksite.
(3)
o
o
o
o
o
Changes to a
work schedule
(such as flex
time, or part
time)? Please
describe the
changes to the
work schedule.
(4)
o
o
o
o
o
Page 11 of 30
Moving the
employee to
another job (or
reassignment)
? What type of
work was the
employee
doing before
reassignment
and what type
of are they
doing after?
(13)
o
o
o
o
o
Changes in
workplace
policy? What
workplace
changes were
modified? (14)
o
o
o
o
o
Formal or
company
education of
co-workers?
Please
describe how
the company
was/is going to
educate coworkers? (5)
o
o
o
o
o
Providing an
interpreter,
reader, job
coach, or
personal
attendant
services?
What services
were
provided? (6)
o
o
o
o
o
Page 12 of 30
Providing
information in
an alternative
format (e.g.,
large print,
taped text,
Braille, etc.)?
What
alternative
formats were
provided? (7)
o
o
o
o
o
Working from
home or
telework?
What
arrangements
were made
(number of
hours in a
week)? (8)
o
o
o
o
o
Are there
accommodatio
ns solutions
that we have
not talked
about? If yes,
please specify.
(9)
o
o
o
o
o
Modified the
employee's
work station
(moved,
rearranged, or
ergonomic)?
How was the
work station
modified? (10)
o
o
o
o
o
Page 13 of 30
Q15 How effective was the accommodation?
o Extremely effective (1)
o Effective (2)
o Neutral (3)
o Somewhat effective (4)
o Not effective at all (5)
o Do not know (6)
Page Break
Page 14 of 30
Q16 Please describe why the accommodation was or was not effective?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Q17 Approximately how much did the accommodation cost (or is expected to cost)?
o One-time cost, amount $ (1) ___________________________________________
o Annually, amount $ (2) _______________________________________________
o Do not know (3)
Skip To: Q20 If Approximately how much did the accommodation cost (or is expected to cost)? =
Annually, amount $
Skip To: Q20 If Approximately how much did the accommodation cost (or is expected to cost)? >=
Annually, amount $
Q20 Who helped (or will help) pay for this accommodation? (All that apply)
▢
▢
▢
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Employer (1)
Employee (2)
Rehabilitation Services (3)
Insurance Company (4)
Other (5) ________________________________________________
Do not know (6)
Page 15 of 30
Display This Question:
If Who helped (or will help) pay for this accommodation? (All that apply) = Employer
Q21 If "Employer," what was the source of funding for this accommodation?
o Departmental Funds (1)
o Human Resource Funds (2)
o Company General Funds (3)
o Specific Accommodation - Related Funds (4)
o Other (5) ________________________________________________
o Do not know (6)
Q22 Who has the authority to authorize expenditure for accommodations?
▢
▢
▢
▢
▢
Local Managers/Supervisors (1)
Human Resource Representatives (2)
Corporate/General Management (3)
Other. Please explain. (4) ________________________________________________
Do not know (5)
Skip To: Q24 If Who has the authority to authorize expenditure for accommodations? = Do not know
Page 16 of 30
Q23 How much did (or will) each pay? Enter percentages of cost. This should total to 100%.
(Choose all that apply.)
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▢
▢
▢
▢
▢
Employer (8) ________________________________________________
Employee (9) ________________________________________________
Rehabilitation services (10) _____________________________________
Insurance company (11) _______________________________________
Other. Please Explain. (12) _____________________________________
Do not know (13) _____________________________________________
Q24 In dollars, how much of the cost of the accommodation was beyond what you would have
paid for an employee in the same position who did not have a disability?
For example, an employer might purchase a computer monitor for all of his employees, but an
employee may need a large screen rather than a regular monitor as an accommodation. The
cost difference between the large screen monitor and the regular monitor would be the amount
that we are asking about.
________________________________________________________________
Page Break
Page 17 of 30
Q26 The following is a list of direct benefits that your company may have received from
providing this accommodation. Please answer yes or no to the following:
Yes (1)
No (2)
The accommodation
allowed the company
to hire a qualified
employee (1)
o
o
o
The accommodation
allowed company to
retain a qualified
employee (2)
o
o
o
The accommodation
allowed company to
promote a qualified
employee (3)
o
o
o
The accommodation
eliminated the cost of
training a new
employee (4)
o
o
o
The accommodation
saved workers’
compensation or
other insurance costs
(5)
o
o
o
The accommodation
increased the
accommodated
worker's productivity
(6)
o
o
o
The accommodation
increased the
accommodated
worker's attendance
(7)
o
o
o
o
o
o
o
o
o
Increased diversity of
the company (8)
Other. Please
explain. (9)
Do not know (3)
Page 18 of 30
Q27 Were there any or do you expect any indirect costs for the accommodation (Indirect costs
are those not directly related to providing the accommodation such as lost time because of
training, supervisor's time, loss of production, etc.)?
o Yes (1)
o No (2)
o Do not know (3)
Skip To: Q29 If Were there any or do you expect any indirect costs for the accommodation (Indirect costs
are thos... = No
Skip To: Q29 If Were there any or do you expect any indirect costs for the accommodation (Indirect costs
are thos... = Do not know
Page 19 of 30
Q28 The following is a list of indirect benefits that your company may have received from
providing this accommodation. Please answer yes or no to the following:
Yes (1)
No (2)
Do not know (3)
The accommodation
increased overall
company productivity
(1)
o
o
o
The accommodation
increased overall
company attendance
(2)
o
o
o
The accommodation
increased overall
company morale (3)
o
o
o
The accommodation
increased workplace
safety (4)
o
o
o
The accommodation
increased customer
base (5)
o
o
o
The accommodation
increased profitability
(6)
o
o
o
The accommodation
improved interactions
with co-workers (7)
o
o
o
The accommodation
improved interactions
with customers (8)
o
o
o
Other indirect
benefits. Please
explain. (9)
o
o
o
Page 20 of 30
Q29 Did the information JAN provided help you to understand the ADA or another law?
o Yes (1)
o No (2)
o Do not know (3)
Q30 Was the information used to argue for or make a policy change?
o Yes (1)
o No (2)
o Do not know (3)
Skip To: Q32 If Was the information used to argue for or make a policy change?
= No
Skip To: Q32 If Was the information used to argue for or make a policy change?
= Do not know
Q31 What was the outcome of that policy decision?
o The policy was changed (1)
o The policy was not changed (2)
o The decision about whether to change the policy is still pending (3)
o Confirm/validate/interpret existing policy (4)
o Accommodation decision made (5)
o Other. Please explain. (6) ________________________________________________
o Do not know (7)
Page Break
Page 21 of 30
Page 22 of 30
Q32 Have you visited the JAN website within the last year? ( AskJAN.org )
o Yes (1)
o No (2)
o Do not know (3)
Skip To: Q39 If Have you visited the JAN website within the last year? ( AskJAN.org ) = No
Skip To: Q39 If Have you visited the JAN website within the last year? ( AskJAN.org ) = Do not know
Q36 How was the website to navigate?
o Easy (1)
o Somewhat easy (2)
o Neutral (3)
o Somewhat difficult (4)
o Difficult (5)
o Do not know (6)
Page 23 of 30
Q35 How was it for you to obtain the information that you needed from the website?
o Easy (1)
o Somewhat easy (2)
o Neutral (3)
o Somewhat difficult (4)
o Do not know (6)
Q37 What did you hope to find on the website?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Q38 Did you find it?
o Yes (1)
o If no, please explain. (2) ________________________________________________
Page Break
Page 24 of 30
Q39 How easy or difficult was it to contact JAN?
o Easy (1)
o Somewhat easy (2)
o Neutral (3)
o Somewhat difficult (4)
o Difficult (5)
o Do not know (6)
Q40 How were you treated by the receptionist at JAN?
o Courteously (1)
o Somewhat courteously (2)
o Neutral (3)
o Somewhat not courteously (4)
o Not courteously (5)
o Do not know (6)
Q50 Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Page 25 of 30
________________________________________________________________
Q41 How were you treated by the consultant at JAN?
o Courteously (1)
o Somewhat courteously (2)
o Neutral (3)
o Somewhat not courteously (4)
o Not courteously (5)
o Do not know (6)
Q51 Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Page 26 of 30
Q42 How well did the consultant understand your needs?
o Understood (1)
o Somewhat understood (2)
o Neutral (3)
o Somewhat misunderstood (4)
o Misunderstood (5)
o Do not know (6)
Q52 Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Page Break
Page 27 of 30
Q43 How well did the information that you received meet your needs?
o Met my needs well (1)
o Met my needs somewhat well (2)
o Neutral (3)
o Did not really meet my needs (4)
o Did not meet my needs (5)
o Do not know (6)
Q44 How could the services you received have better met your needs?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Q45 Where would you get the type of information that JAN provides if JAN did not exist?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Page 28 of 30
Q46 Would you use the service again?
o Yes (1)
o No (2)
o Do not know (3)
Q47 Have you referred other people to JAN?
o Yes (1)
o No (2)
Q48 How likely would you be to refer other people to JAN?
o Likely (1)
o Somewhat likely (2)
o Neutral (3)
o Somewhat unlikelyUn (4)
o Unlikely (5)
o Do not know (6)
Q49 We would appreciate any comments or suggestions that you may have about JAN.
________________________________________________________________
________________________________________________________________
________________________________________________________________
Page 29 of 30
________________________________________________________________
Page 30 of 30
| File Type | application/pdf |
| File Title | JAN Employer Survey |
| Author | Qualtrics |
| File Modified | 2018-09-14 |
| File Created | 2018-09-14 |