Comparison Group Survey & PTS

Form Approved

OMB Number 1230-0001

Exp. Date xx/xx/2020

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays an Office of Management and Budget (OMB) control number. The valid OMB Control Number for this information collection is xxxx-xxxx. The time required to participate in the focus group is estimated to average 60 minutes, including the time to review instructions, search existing data resources, gather the data needed and complete and review the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to US Department of Labor, Office of Disability Employment Policy, 200 Constitution Ave., N.W. Washington, DC 20210 and reference the OMB Control Number xxxx-xxxx.

Comparison Group Survey

1. Confirm contact information

   1. Name (first and last name)

   2. Other identifying details: SRBI will confirm identity using phone number and American Job Center enrollment details (e.g., dates of entry). If they cannot confirm, the survey will stop.

2. When you began receiving services from your local workforce center, you self-disclosed disclosed a disability. At that time, what type of disability did you self-disclose?

(Multiple choice – will provide some examples in each category for the SRBI staff)

1. Attention-Deficit/Hyperactivity Disorders

2. Blindness or Low Vision

3. Brain Injuries

4. Deaf/Hard-of-Hearing

5. Learning Disabilities

6. Physical Disabilities

7. Medical Disabilities

8. Mental Health Disabilities

9. Speech and Language Disabilities

10. Developmental/Intellectual Disabilities

11. Autism Spectrum Disorders

The following questions ask about the nature of your disability and how it may affect your ability to return to work. Generally speaking:

3. Do you need help or encouragement attending to your daily activities or chores?

   1. Yes b. No c. Don’t Know d. Refused to Answer

4. Do you take care of anyone else such as a wife/husband, children, grandchildren, parents, friends, other?

   1. Yes b. No c. Don’t Know d. Refused to Answer

5. At the time you enrolled at your local workforce center, did your disability impact your ability to:

   1. Dress?

      1. Yes, No, Don’t Know, Refused to Answer

   2. Go shopping outside your home?

      1. Yes, No, Don’t Know, Refused to Answer

   3. Prepare your own meals?

      1. Yes, No, Don’t Know, Refused to Answer

   4. Drive a car?

      1. Yes, No, No car/No access to car, Don’t Know, Refused to Answer

   5. Use public transportation?

      1. Yes, No, Don’t Know, Refused to Answer

6. Does (or did) your disability impact your ability to find a job and return to work?

   1. Yes, No, Don’t Know, Refused to Answer

7. If YES to Question 6, did the services you received at your local workforce center help you in obtaining your current job?

   1. Yes, No, Don’t Know, Refused to Answer

8. As a result of your enrollment in an American Job Center, did you receive a certification or diploma after completing a training program? List certificates.

9. If you are currently employed, are you working in a job related to the training you received?

   1. Yes

   2. No

   3. Don’t Know

   4. Refused to Answer

[INSERT ENDING PARAGRAPH DESCRIBING MONETARY INCENTIVE AND CONFIRMING ADDRESS]

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