Home Care Bargaining Survey 2023 Information About You Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. City Question Title * 4. Cell Phone (Enter number without dashes or parentheses) By providing my phone number, I understand that District 1199 NE may use automated calling technologies and/or text message me on my cellular phone on a periodic basis. District 1199 NE will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Text a reply “STOP” to stop receiving texts from District 1199 NE. Question Title * 5. Email Address Question Title * 6. Preferred Language Question Title * 7. Which race describes you best? White Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race (please specify) Question Title * 8. As a home care provider, I provide services for the following number of Consumers (through Allied or Sunset Shores) No one currently - I'm looking for a consumer 1 Consumer 2 Consumers 3 or more Consumers Question Title * 9. As a home care provider through Allied or Sunset Shores, I provide services to a Consumer who is: (check all that apply) My child A family member Someone I live with Someone who I am not related to and do not live with Question Title * 10. For all your consumers combined through Allied or Sunset Shores, how many hours do you work on average? Less than 10 hours per week Between 10 and 20 hours per week Between 20 and 30 hours per week Between 30 and 40 hours per week Between 40 and 50 hours per week Between 50 and 60 hours per week More than 60 hours per week Question Title * 11. What is your age range? 16-24 25-34 35-44 45-54 55-64 65-74 75 or above Question Title * 12. If you have another job besides Allied or Sunset Shores, where do you work? Next
