Changes to the Establishment Background Questionnaire

[Changes to the Establishment Background Questionnaire]

Information About You

Many workers are being asked to complete this survey. Your answers to these questions will help us know that workers with differing amounts of experience and different backgrounds are included.

Please read each question carefully and mark your answer by putting an X in the box beside your answer, or by writing an answer on the line provided.

1. What is the title of your current job? (PLEASE PRINT)

2. For how long have you worked at this job? (Mark one box)

T en years or more

At least 6 years, but less than 10 years

At least 3 years, but less than 6 years

At least 1 year, but less than 3 years

At least 3 months, but less than 12 months

A t least 1 month, but less than 3 months

L ess than 1 month

3. In your current job, are you employed by (Mark one box)

G overnment

Private for-profit company

N onprofit organization including tax exempt

and charitable organizations

S elf-employed

F amily business

4. If you are working in the family business, is this business incorporated?

Y es

N o

N ot working in a family business

5. In what year were you born? ............... 1 9 ___ ___ ___ ___

6. Are you male or female? (Mark one box)

M ale

F emale

7. Are you Hispanic or Latino? (Mark one box)

Y es

N o

8. What is your race? (Mark one or more boxes)

A merican Indian or Alaska Native

Asian

Black or African American

N ative Hawaiian or Other Pacific Islander

W hite

9. Do you have any of the following long-lasting conditions?

Yes No

a . Blindness, deafness, or a severe vision or hearing impairment?

b . A condition that substantially limits one or more basic physical activities such as walking, climbing stairs, reaching, lifting, or carrying?

10. Because of a physical, mental, or emotional condition lasting 6 months or more, do you have any difficulty doing any of the following activities?

Yes No

a. Learning, remembering, or concentrating?

b . Dressing, bathing, or getting around inside the home?

c . Going outside the home alone to shop or visit a doctor's office?

d. Working at a job or business?

119. Indicate the highest level of education that you have completed (please check only one box):

L ess than a High School Diploma

H igh School Diploma – or the equivalent (for example, GED)(or GED or High School Equivalence Certificate)

P ost-Secondary Certificate - awarded for training completed after high school (for example, in agriculture or natural resources, computer services, personal or culinary services, engineering technologies, healthcare, construction trades, mechanic and repair technologies, or precision production) in Personnel Services, Engineering-related Technologies, Vocational Home Economics, Construction Trades, Mechanics and Repairers, Precision Production Trades)

S ome College Courses

A ssociate's Degree (or other 2-year degree)

B achelor's Degree

P ost-Baccalaureate Certificate - awarded for completion of an organized program of study; designed for people who have completed a Baccalaureate degree but do not meet the requirements of academic degrees carrying the title of Master.

M aster's Degree

P ost-Master's Certificate - awarded for completion of an organized program of study; designed for people who have completed a Master's degree but do not meet the requirements of academic degrees at the doctoral level.

F irst Professional Degree - awarded for completion of a program that

• requires at least 2 years of college work before entrance into the program,

• includes a total of at least 6 academic years of work to complete, and

• provides all remaining academic requirements to begin practice in a profession.

D octoral Degree

P ost-Doctoral Training

Yes No

1 0. Are you deaf or do you have serious difficulty hearing? .........

1 1. Are you blind or do you have serious difficulty seeing even

when wearing glasses? ...............................................................

12a. Because of a physical, mental, or emotional condition,

d o you have serious difficulty concentrating, remembering,

or making decisions? .................................................................

b. Do you have serious difficulty walking or climbing stairs? .....

c. Do you have difficulty dressing or bathing? .............................

13. Because of a physical, mental, or emotional condition,

do you have difficulty doing errands alone such

as visiting a doctor’s office or shopping? ................................

Your Professional Certifications

1. Please write the names of job-related professional certifications that you have earned:

a.________________________________________________________________

b.________________________________________________________________

c.________________________________________________________________

d.________________________________________________________________

e.________________________________________________________________

Your Apprenticeship Certificates

2. Please write the names of job-related apprenticeship programs that you have completed:

a.__________________________________________________________

b.__________________________________________________________

c.___________________________________________________________

d.___________________________________________________________

e.___________________________________________________________

Your Association Memberships

Finally, we would like to know about the professional associations to which you belong.

1. Are you currently a member of the following job-related association(s)? (Please respond for each association listed.) one or more professional associations? (Please respond for each association listed; if none are listed below, please skip to Question 2.)

<association name> Yes No

<association name> Yes No

2. Please print the names of any other job-related associations to which you belong:

a.

b.

c.