Frontline Supervisor and Manager Training Program: Learner Information (C5)

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.)

Signature (type your full name):

Today's Date:

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* 2. Agency of Employment

Compass

SEEC

Other (please specify)

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* 3. Title:

Mr.

Mrs.

Miss.

Ms.

Other (please specify)

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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.

Birthdate

Date

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

Street Address
Example: 123 Fancy Street, Apt. 22

City
Example: Baltimore

State
Example: MD (for Maryland)

Zip Code
Example: 20292

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

White or Caucasian

Black or African American

Asian

Hispanic/Latinx

Hawaiian/Pacific Islander

Native American or American Indian

Other (please specify)

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* 11. Gender:

Male

Female

Other

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* 12. National Origin

AFRICAN

AMERICAN

ASIAN

CENTRAL & LATIN AMERICAN

EUROPEAN

MIDDLE EASTERN

NORTH AMERICAN (EXCLUDING USA)

OCEANIA

OTHER (PLEASE SPECIFY:_______________)

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* 13. Highest Level of Education:

Some high school or less

High school Diploma/ GED Equivalent

Some College

Associate's Degree

Bachelor's Degree

Advanced Degree (Master's, PhD, Dr, Other)

Trade School

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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?

Yes

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.

Frontline Supervisor and Manager Training Program: Learner Information (C5)

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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.

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

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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?

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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.

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* 17. Language(s) Spoken

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* 18. Job Title

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* 19. Social Security Number

Frontline Supervisor and Manager Training Program: Learner Information (C5)

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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.

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

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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?

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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.

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* 17. Language(s) Spoken

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* 18. Job Title

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* 19. Social Security Number

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

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

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

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