Survey Design for the Frog Hollow Job Center Skill BankPrepared by: Sharon
Herzberger·Professor of Psychology·Trinity College Prepared for: Hartford Areas Rally Together·660
Park Avenue Trinity Center for Neighborhoods HART Jobs Center Optional InformationThe information requested on this sheet is optional. You do not need to provide this information to participate in our Jobs Center and this information will not be shared with potential employers without your agreement. However, occasionally opportunities arise for people with special needs or particular background circumstances. If we learn of such an opportunity and if we know that you are eligible, we will try to contact you. Date:_______________________ Name: First_____________M.I.______Last__________________ Soc. Sec. #:_________________________ Age:________________Birthdate: Mo._____Day______Yr.________ Sex (circle one):
Child care needed during work hours (circle one):
Barriers to employment (circle any that apply to you):
Are you or is anyone else in your family unit receiving any government financial assistance? Circle any that apply:
Are you a veteran? (Circle one)
Date:_______________________ Program Interest:_________________________ Name: First_____________M.I.______Last__________________ Soc. Sec. #:_________________ Address: No. & St.________________City___________State ___Zip _______ Home Telephone:________________ Are you employed?
Work Phone:____________________ Circle your highest level of education:
What jobs are you interested in? _____________________________________________________________ _____________________________________________________________ Circle any of the jobs listed above in which you have had experience. List training you have received and skills acquired that potential employers should know about. _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Do you have computer skills? If so, list _____________________________________________________________ _____________________________________________________________ What rate of pay do you expect to earn? ________ per hr. __________per yr. When are you available for work? 1st shift____2nd shift____3rd shift____Seasonal (when:______) Would you want to work: Part-time____Full-time____ Employment History
If you move and we lose track of you, who will know how we may contact you? List name and phone number _______________________________________
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