Disability and Employment Readiness Questionnaire Form
Please complete the Disability and Employment Readiness Questionnaire Form to help us understand your current employment readiness and identify any support you may need for work preparation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your current employment status?
*
Unemployed
Employed part-time
Employed full-time
Student
Other
What are your main goals for employment?
*
Which of the following skills do you feel confident about?
Communication
Teamwork
Problem-solving
Time management
Technical/computer skills
Other
What do you feel are your main barriers to employment?
Lack of experience
Lack of qualifications
Transportation
Accessibility at workplaces
Need for assistive technology
Other
What types of support or accommodations would help you prepare for work?
When are you available to start employment or work preparation programs?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is there anything else you would like us to know about your employment readiness or support needs?
Submit
Should be Empty: