Please complete the questions below with accurate data. In some cases, we may verify your information with your agency's human resources department. All information collected is safely stored and completely confidential. This form is secure. If you would like to read about SurveyMonkey's security features, click here: https://www.surveymonkey.com/mp/legal/security/

Required questions are marked with an asterisk (*). Other questions are optional.

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* 1. This program is funded by the State of Maryland’s EARN Maryland Grant Program, administered by the Maryland Department of Labor. As a recipient of EARN Maryland funds, this program is required by law to collect certain demographic information from training participants and to provide such information to Labor for reporting purposes. Any demographic information provided to Labor will not contain personal identifiable information.

By enrolling in this program, I grant permission to share my demographic information with Labor. I understand and agree with these conditions. (typing your name below serves as your electronic signature.)

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* 2. Agency of Employment

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* 3. Title:

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* 4. First Name:

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* 5. Middle Initial:

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* 6. Last Name:

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* 7. Preferred Name:

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* 8. Date of Birth: 
Your birthday, NOT today's date.

Date

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* 9. Home Mailing Address:
(We will send your Certificate of Completion to this address)

The answers to the questions below are used to anonymously track the characteristics of people who take the training.

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* 10. Race

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* 11. Gender:

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* 12. National Origin

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* 13. Highest Level of Education:

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* 14. Have you served or are you serving in the United States military OR is your spouse currently serving or have they previously served in the United States military?

The answers to the following two questions are used to anonymously compare with your rate of pay and hours after completing the training. This helps to determine the impact of the training.

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* 15. Rate of Pay:
How much are you paid per hour ? (just the number, no words)

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* 16. Hours per week:
On average, how many hours do you work per week? Please enter 1 number, not a range.

The last three questions are optional.

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* 17. Language(s) Spoken

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* 18. Job Title

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* 19. Social Security Number

When you've completed the form, click "submit" below.

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