Disability Issues in Employment Survey

* - REQUIRED FIELDS

Personal Information::

*Male or Female ::

Male Female

*County of Residence ::

*Age ::

*Do you have a disability? ::

Yes No

If yes, describe your disability

*Please check highest level of education completed:

Please check all resources that apply:

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)

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 ::

THANK YOU FOR HELPING WITH OUR SURVEY!