Department of Labor Generic Clearance for the Job Accommodation Network (JAN) Customer Satisfaction Survey

OMB Control No. 1225-0059
Expiration Date 11/30/2020

JAN Individual 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 23

Q3 Was the accommodation you discussed with the JAN consultant about:

o Keeping your current job (8)
o Applying for a new job (1)
o A job that you just started or are going to start (2)
o Being promoted (5)
o Other. Please explain. (6) ________________________________________________
o Do not know (7)
Page Break

Page 2 of 23

Q6 What is your 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 Prefer not to answer (7)
Q7 What is your gender?

o Male (1)
o Female (2)
o Transgender (3)
o Prefer not to answer (4)

Page 3 of 23

Q8 What is your 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)
Prefer not to answer (9)

Q53 What is your ethnicity? (Choose all that apply)

▢
▢
▢

Hispanic or Latino (1)
Not Hispanic or Latino (2)
Prefer not to answer (3)

Page 4 of 23

Q9 What is your 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 Prefer not to answer (9)
Page Break

Page 5 of 23

Q4 How many years have you been with the company?
________________________________________________________________

Q5 What is the wage for your job? (pick one)

o By hour ($) (1) ________________________________________________
o Annually ($) (2) _______________________________________________
o Do not know (3)
Page Break

Page 6 of 23

Q12 Who makes the decision whether the company will provide an accommodation? (Mark all
that apply)

▢
▢
▢
▢
▢
▢

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 7 of 23

Q54 What did the accommodation solution include?

Page 8 of 23

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 9 of 23

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 10 of 23

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 11 of 23

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 12 of 23

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)

▢
▢
▢
▢
▢
▢

Employer (1)
Employee (2)
Rehabilitation Services (3)
Insurance Company (4)
Other (5) ________________________________________________
Do not know (6)

Page 13 of 23

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 14 of 23

Q23 How much did (or will) each pay? Enter percentages of cost. This should total to 100%.
(Choose all that apply.)

▢
▢
▢
▢
▢
▢

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 15 of 23

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 16 of 23

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)
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)
Page 17 of 23

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 18 of 23

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 19 of 23

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 20 of 23

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 21 of 23

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 22 of 23

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 23 of 23