Retaining Employment and Talent after Injury/Illness Network (RETAIN) Demonstration Projects and Evaluation

Retaining Employment and Talent after Injury/Illness Network (RETAIN) Demonstration Projects and Evaluation

RETAIN Baseline Participant Form Part 1, revised for Phase 2

Retaining Employment and Talent after Injury/Illness Network (RETAIN) Demonstration Projects and Evaluation

OMB: 1230-0014

Document [docx]
Download: docx | pdf

Shape4

Shape3

OMB Control No.: 1230-0014

Expiration date: 05/31/2022

[STATE NAME] RETAIN Project

Retaining Employment & Talent after Injury/Illness Network

Participant Enrollment Information Form: Part One
TO BE COMPLETED BY PARTICIPANT

*ALL FIELDS REQUIRED*

1. Full Name

FIRST MIDDLE LAST

2. Mailing Address:

STREET (OR P.O. BOX) CITY STATE ZIP

3. Email address:

@

4. Phone Number:

| | | | - | | | | - | | | | |

5. Date of Birth:

| | | / | | | / | | | | |

MONTH DAY YEAR

6. Social Security Number:

| | | | - | | | -| | | | |

7. What language do you prefer to communicate in?

MARK ONE ONLY

English

Spanish

Other language (please specify)


8. What is your sex?

MARK ONE ONLY

Male

Female



9. Are you of Hispanic, Latino, or Spanish origin?

MARK ONE ONLY

Yes

No


10. What is your race?

MARK ALL THAT APPLY

White

Black or African-American

American Indian or Alaska Native

Asian

Hawaiian or Pacific Islander







Shape5

11. What is your highest level of educational attainment?

MARK ONE ONLY

Less than a high school diploma

High school diploma, GED or certificate of completion

Occupational certificate/license or 2-year college degree

4-year college degree (bachelor’s degree)

Post-graduate degree (master’s, doctorate, professional)


12. Do you currently have an injury or illness that limits the kind or amount of work you can do?

Yes

No


13. In general, would you say your current health is?

MARK ONE ONLY

Excellent

Very Good

Good

Fair

Poor




14. In the last 12 months, did you work at a job that paid you more than $1,000 a month (before taxes and deductions)?

Yes

No


15. What best describes your current employment status…

MARK ONE ONLY

Not employed

Self-employed

Employed at private company, non-profit, or government




16. How many hours per week did you usually work before your injury/illness?

_________________





17. How long has it been since you last worked?

MARK ONE ONLY

I worked today

No more than a week ago

More than a week ago but no more than a month ago

More than a month ago but no more than three months ago

More than three months ago but no more than six months ago

More than six months ago











Shape6 18. How long have you been continuously employed at your current job (or most recent job, if not currently employed)?

No more than 6 months

More than 6 months but no more than 1 year

More than 1 year but no more than 2 years

More than 2 years but no more than 5 years

More than 5 years




19. Within the last 3 years, did you apply for or receive disability benefits from the Social Security Administration --- either Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI)?

Yes

No




20. Have you ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?

Yes

No



21. Are you now covered by any of the following types of health insurance?



MARK ALL THAT APPLY:


a. Private insurance plan through own employer

b. Private insurance plan through family member’s employer

c. Private insurance plan not connected to any employer

d. Medicare

e. Medicaid

f. Veteran’s Health Plan

g. Other (please specify)




22. Are you currently receiving income from any of the following sources?


MARK ONE PER ROW


YES

NO

DON’T KNOW

a. Social Security disability (SSDI or SSI)?

b. Veterans’ benefits?

c. Workers’ compensation?

d. Employer-provided or other private disability insurance?

e. Other public programs (specify)




Thank you for completing this form. Please return it to xxxx. If you have any questions, please contact xxxx.

Public reporting burden for this collection of information is estimated to average 10 minutes per respondent. Send comments concerning this burden estimate or any other aspect of this collection of information to the U.S. Department of Labor, Office of Disability Employment Policy, Room S-1313, Constitution Ave., Washington, DC 20210. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. (Paperwork Reduction Act OMB Control Number, 1230-0014.)




Privacy Act Statement
Collection and Use of Personal Information




The following statement is made in accordance with the Privacy Act of 1974 (5. U. S. C. 552a). Information collected will be handled and stored in compliance with the Freedom of Information Act and the Privacy Act of 1974, as amended (5 U.S.C. 552a). Furnishing us this information is voluntary. However, failing to provide all or part of the information will prevent you from participating in the RETAIN demonstration project.

We will use the information you provide for the RETAIN project. Disclosure of information from this system of records will be made to the Social Security Administration and a third party organization under contract to the Social Security Administration for the performance of project management activities directly related to this system of records. The United States Department of Labor, Office of Disability Employment Policy and its employees will use the information you provide in de-identified format for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent. Per the Federal Cybersecurity Enhancement Act of 2015, Federal information systems are protected from malicious activities through cybersecurity screening of transmitted data.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleRETAIN PARTICIPANT ENROLLMENT FORM
SubjectSAQ
AuthorU.S. Department of Labor
File Modified0000-00-00
File Created2021-02-11

© 2024 OMB.report | Privacy Policy