Emerging Leaders Initiatives

Appendix B-3 Intake Survey

OMB Approval No:_______

Expiration Date:__________

Background Information

1. Your first name <text box>*

2. Your last name <text box>*

3. Business Name <text box>*

4. Preferred e-mail address <text box>*

5. Preferred telephone number <text box>

6. Business primary street address 1 <text box>*

7. Business primary address 2 <text box>

8. Business primary city <text box>*

9. Business primary state (select one)*

• AK

• AL

• AR

• AS

• AZ

• CA

• CO

• CT

• DC

• DE

• FL

• FM

• GA

• GU

• HI

• IA

• ID

• IL

• IN

• KS

• KY

• LA

• MA

• MD

• ME

• MH

• MI

• MN

• MO

• MP

• MS

• MT

• NC

• ND

• NE

• NH

• NJ

• NM

• NV

• NY

• OH

• OK

• OR

• PA

• PR

• PW

• RI

• SC

• SD

• TN

• TX

• UT

• VA

• VI

• VT

• WA

• WI

• WV

• WY

10. Business primary Zip Code <text box>*

11. What is your job title? (select all that apply)

• President

• Owner

• CEO

• COO

• CFO

• Vice-President

• Other <text box>

12. This business began in the following year (Please use YYYY format) <text box>

13. Do you currently own all or part of this business?

    • Yes

    • No

14. Since what year have you been an owner, or part owner, of this business (Please use YYYY format)? <text box>

15. Please choose the location of your SBA Emerging Leaders sessions. [selection options vary each year]

16. How did you originally find out about the program? (Select all that apply)

    • Direct recruitment by the host organization Program Manager

    • E-mail or online newsletter from the host organization Host organization/Program website

    • Instructor referral

    • Past participant referral Local SBA referral

    • Technical assistance provider other than the SBA (SBDCs, SCORE, USEAC, WBC, etc.) referral

    • E-mail or online newsletter from a technical assistance provider/local organization

    • Lender

    • Local event, newspaper, television, or radio

    • National newspaper/Magazine

    • Word of mouth

    • Social Media, please indicate website <text box>

    • Other <text box>

The next two questions will ask you to identify the main sub-industries of your business. Please take your time choosing your sub-industries because they will be used by your Instructor to obtain reports you will need for the financial analysis module.

17. Select the industry that best describes your business (NAICS Code selection drop down)

18. Please select up to three sub-industries (NAICS codes) that best fits your business. (NAICS Code sub-industry drop down)

19. Do any of the following business certificates or designations currently apply to this business (select all that apply)?

• SBA 8(a) certified business

• SBA HUBZone certified business

• SBA Small Disadvantaged Business

• Minority-owned business

• Veteran or service member-owned business

• Women-owned business

• Located on Native American-owned land

• Other (please specify)

• No certificates or designations apply

20. What percentage of the business is female owned?

    • <Text box>

    • Do not Know

21. What percentage of the business is minority owned?

    • <Text box>

    • Do not Know

22. What is the legal structure of the business?

1. Sole Proprietorship

2. LLC

3. S-Corporation

4. Partnership

5. Corporation

6. Other (Please specify) <Text box here >

7. Do not know

23. Does your business have a 9-digit DUNS number?

    • Yes b. No c. Do not know

24. What is the business EIN number, if applicable? <Text box here>

The business EIN would allow SBA to track your business growth over time by matching the record to other federal datasets. Your EIN will be kept strictly confidential and securely stored.

Business Operations

25. What was the total revenue for the business during [YEAR 1]? This figure should match gross receipts/sales on your tax return. Be sure to double check the number of zeros you enter (e.g., $300,000 vs $3,000,000 makes a big difference)

• <text box>
  
  

26. What was the profit or loss of the business during [YEAR 1]? This figure should match net profit or loss on your tax return. Be sure to double check the numbers you enter (e.g. $300,000 vs -$300,000 makes a big difference)

• text box>
  
  

27. What is the highest number of paid full-time employees (including paid owners) the business had during [YEAR 1]? Full-time is 35+ hours per week.

• <text box>
  
  

28. Of all full-time employees counted in the previous question, how many lived in the same city or town as the primary business location during [YEAR 1]? Please enter "0" (zero) if no full-time employees live in the same city or town as the business, including yourself.

• <text box>
  
  

29. What is the highest number of paid part-time employees (including paid owners) the business had during [YEAR 1]? Part-time is fewer than 35 hours per week.

• <text box>

30. Does the business have formal professional development programs in place for employees, such as individual training opportunities or group training workshops? Professional development does not include on-the-job orientation for new employees.

• Yes

• No

31. Does the business offer any of the following benefits to full-time employees (including paid owners)?

1. Yes

2. No

• Paid holidays

• Paid sick time

• Paid vacation time

• Health care insurance

• Dental insurance

• Retirement or pension plan (e.g., 401(k), SEP)

32. Did the business hire any new full-time employees in [Year 1]?

    • Yes

    • No

Financing and Contracts

33. Did the business obtain one or more of the following sources of new financing during [Year 1] (select all that apply)?

• SBA-backed loan (e.g.7(a),Microloan)

• Non-SBA loan

• Equity capital

• Line of credit, excluding credit cards

• Other (please specify)

• None

34. [If yes to question above] Please provide the amount of new financing obtained during [Year 1]:

• SBA-backed Loan Amount <text box>

• Non-SBA Loan Amount <text box>

• Equity Capital Amount <text box>

• Line of Credit Amount <text box>

• Other Amount <text box>

35. In [Year 1], was the business awarded one or more new prime contracts with, or subcontracts associated with, a government, corporate or nonprofit entity (excluding standard purchase agreements)?

• Yes

• No

36. [If yes to question above] Provide the following information for each type of contract or subcontract obtained during [YEAR 1]: Enter "0" (zero) if your business had no contracts/subcontracts of that type in [Year 2]. If you do not have exact values, please give your best estimate for each type.

Entity	Number of Prime Contracts	Number of Subcontracts
Federal Government
State Government
Local Government, including state, city, county, or parish
Tribal Government
Corporate
Nonprofit, including hospitals, academic institutions (college or university), cultural centers, or other large nonprofit organization

Entity	Value of Prime Contracts	Value of Subcontracts
Federal Government
State Government
Local Government, including state, city, county, or parish
Tribal Government
Corporate
Nonprofit, including hospitals, academic institutions (college or university), cultural centers, or other large nonprofit organization

Growth Management

37. Please indicate the frequency with which you do the following to manage your business.

	Never	Seldom	Sometimes	Usually	Always	Not applicable
I make strategic decisions based on written goals or a growth plan
I use financial data and analysis to make decisions about operations
I consider the profiles of my most profitable customers when I create new business strategies (e.g., for marketing, new market segments)
I use well-thought out strategies when I market and sell products/services
I use well-thought out procedures when I assess human resource needs
I use well-thought out procedures when I evaluate employee performance
I make an effective case to banks and investors when I seek additional funding
I respond effectively when I bid on government contracts

38. In [Year 1] what resources (if any) did you use to help achieve your business goals and needs (select all that apply)?

• Small Business Administration (SBA) district office

• SBA website

• Small Business Development Centers (SBDC)

• SCORE Association

• Women’s Business Centers (WBC)

• Veteran’s Business Outreach Centers (VBOC)

• U.S. Export Assistance Center (USEAC)

• Procurement Technical Assistance Center (PTAC)

• Business or industry association

• Lender services

• Chamber of Commerce

• State and local government economic development office

• Friends and colleagues

• Others (e.g. professional business coach , incubator or accelerator program) <Text box here>

• None

39. How strongly do you agree or disagree with the following statement: “My region is currently home to a well-developed small business ecosystem of resources that support business growth.”

• Strongly agree

• Agree

• Neutral

• Disagree

• Strongly disagree

40. Did you or your business donate time or money to voluntary organizations in the local community of your business?

1. Yes

2. No

• Charitable organizations e.g. nonprofits, religious organizations, academic institutions

• Business-related organizations e.g. Chambers of Commerce, local chapter of a professional association

Demographic Information

41. What is your gender?

    • Male

    • Female

    • Prefer not to answer

42. Please select all ethnic/racial categories that apply.

    • Asian

    • Black or African American

    • Native Hawaiian or Other Pacific Islander

    • White or Caucasian

    • American Indian or Alaska Native

    • Prefer not to answer

43. Are you Hispanic or Latino?

    • Yes, Latino or Hispanic

    • No, not Latino or Hispanic

    • Prefer not to answer

44. Do you consider yourself a person with a disability?

    • Yes

    • No

    • Prefer not to answer

45. Please indicate your highest level of education:

1. Some high school or less

2. High school diploma or GED

3. Some college

4. Associate’s degree

5. Bachelor’s degree

6. Some graduate school

7. Master’s degree or equivalent

8. Doctorate, law, or medical degree or equivalent

9. Prefer not to answer

46. Please indicate your military service:

1. None

2. Veteran

3. Service Disabled Veteran

4. Active Military

5. Active National Guard or Reservist