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*Age ::
*Do you have a disability? :: Yes No
    If yes, describe your disability
   
*Please check highest level of education completed:
Grade School Some High School
High School Diploma GED
Some College Associates Degree
Bachelor's Degree Masters Degree
   
Please check all resources that apply:
SSI SSDI
Food Stamps Cash Assistance
Employment Other
   
Please answer the following questions ::
   
*1. Are you currently employed? :: Yes No
      If yes, are you employed full-time
      or part-time?		 Full-time Part-time
   
*2. What barriers to employment did you encounter prior to or after being hired for your current position?
   
*3. Have you previously been employed?:: Yes No
      If no, go to Question 5
   
      a). In which county are/were you
          employed?
   
      b) Who is/was your employer?
   
      c). What is/was your job?
   
      d) Did you require the
          services/assistance of an agency
          to obtain and maintain employment? 		Yes No
          If yes, please list which agencies (CareerLink, OVR, MH/MR, etc.) assisted you:
 
   
*4. Are you currently seeking employment? :: Yes No
   
*5. Do you wish to be employed :: Full-time Part-time
   
*6. Have you applied to any companies within the following 6 Counties for employment?
(Please check all that apply)
Cameron Clearfield
Elk Jefferson
McKean Potter
Other
      If other, please specify:
   
      a). Were you given an interview? Yes No
   
      b) How do you feel the company
          evaluated your application?
   
      c). Do you feel companies in PA
          and/or these counties are open
          to hiring people with disabilities? 		Yes No
   
*7. Do you feel these counties have the resources to enable persons with disabilities to obtain and maintain employment? :: Yes No
   
  8. Please share any additional comments on this issue
   
*9. Are you a registered voter? :: Yes No
   
Optional Information ::
   
Please send me more information on LIFT and the Regional Action Teams.
I wish to register to vote, please send me a Voter Registration Card.
I wish to become involved with my Regional Action Team, please put me on your mailing list.
I wish to start a Regional Action Team in my area.
I wish to become involved with a Commission on Employment for Persons with Disabilities.
   
Name ::
Address ::
City ::
Zip Code ::
Phone ::
Email ::