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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.
*
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.)
(Required.)
Signature (type your full name):
Today's Date:
Questions
*
2.
Agency of Employment
(Required.)
Compass
SEEC
Other (please specify)
*
3.
Title:
(Required.)
Mr.
Mrs.
Miss.
Ms.
Other (please specify)
*
4.
First Name:
(Required.)
5.
Middle Initial:
*
6.
Last Name:
(Required.)
7.
Preferred Name:
*
8.
Date of
Birth:
Your
birth
day, NOT today's date.
(Required.)
Birthdate
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
*
9.
Home Mailing Address:
(We will send your Certificate of Completion to this address)
(Required.)
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.
*
10.
Race
(Required.)
White or Caucasian
Black or African American
Asian
Hispanic/Latinx
Hawaiian/Pacific Islander
Native American or American Indian
Other (please specify)
*
11.
Gender:
(Required.)
Male
Female
Other
*
12.
National Origin
(Required.)
AFRICAN
AMERICAN
ASIAN
CENTRAL & LATIN AMERICAN
EUROPEAN
MIDDLE EASTERN
NORTH AMERICAN (EXCLUDING USA)
OCEANIA
OTHER (PLEASE SPECIFY:_______________)
*
13.
Highest Level of Education:
(Required.)
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
*
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?
(Required.)
Yes
No
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.
*
15.
Rate of Pay:
How much are you paid per hour ? (just the number, no words)
(Required.)
*
16.
Hours per week:
On average, how many hours do you work per week? Please enter 1 number, not a range.
(Required.)
The last three questions are optional.
17.
Language(s) Spoken
18.
Job Title
19.
Social Security Number
When you've completed the form, click "submit" below.
