Participant Demographics and Work History
Participant Code
*
Date
-
Month
-
Day
Year
Date
Age
Gender
Male
Female
Other
Community and State of Residence
E.g. Anchorage, Alaska
Race
American Indian / Alaska Native
Asian
Black / African American
Native Hawaiian / Pacific Islander
White / Caucasian
Multi-racial
Other
Ethnicity
Hispanic / Latino
Not Hispanic / Latino
Prefer not to say
Primary language spoken at home
What is your highest level of education?
No formal schooling
Elementary education (grades 1-8)
Some high school, no high school diploma
Special education certificate of attendance
High school diploma equivalent (e.g. GED)
High school diploma
Some college, no degree
Associate degree / vocational technical certificate
Bachelor's degree
Master's degree or higher
Other
What is your current living situation? Select all that apply.
I live alone.
I live with others.
I live in temporary housing.
If you live with others, who are they? Select all that apply.
Partner or spouse
Children
Parents
Grandparents
Other family
Roommate(s)
Other
Do you have a diagnosis of a psychiatric disability?
*
Yes
No
If no, you do not qualify for this study
If yes, what is your diagnosis?
Do you receive any of the following public benefits?
Social Security Income
Social Security Disability Income
Housing Assistance / Section 8
Public Health Care Benefits (i.e., Medicare, Medicaid)
Adult Public Assistance
TANF
WIC
Other
Are you currently receiving services from any of the following? Check all that apply.
Division of Vocational Rehabilitation
Tribal Vocational Rehabilitation
Community Mental Health Center
Veteran's Affairs
Independent Living Center
Developmental Disabilities Agency
One Stop Job Center
Other
Are you a veteran?
Not a veteran
Non-disabled veteran
Disabled veteran
Service-connected disabled veteran
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Are you currently unemployed?
*
Yes
No
If yes, how many months have you been unemployed?
OR
I have never been employed
List jobs you have worked in the past 10 years.
Have you ever been self-employed?
Yes
No
If yes, when?
If yes, what was your business?
Have you had difficulty finding and maintaining employment?
Yes
No
If yes, please explain your difficulty.
What are your job preferences?
Job type:
Job location:
i.e. What community?
Work hours:
e.g. 9 A.M. to 3 P.M. Tuesday and Thursday
Wages/Salary:
e.g. $10.00 an hour
Does your disability impact your career choices?
Yes
No
If yes, please explain.
E.g. Schedule, type of work
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