DSAGC Employment Questionnaire

The goal of this questionnaire is to give the Down Syndrome Association of Greater Cincinnati a better understanding of your employment history, desires, goals, and preferences. With this information, we will be able to help match employers with interested candidates who are qualified for the position and ready to become employed. Note, all information will be kept confidential until permission is given.

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* 1. First and Last Name

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* 2. Email Address

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* 3. Have you ever been employed?

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* 4. Are you currently employed?

Yes

If yes, are you interested in pursuing a different job / career path?

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* 5. Do you have a ride to work?

Yes

Other (please specify)

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* 6. How far from home are you willing to travel for work?

5 minutes

10 minutes

15 minutes

25 + minutes

Other (please specify)

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* 7. How would you get to work?

Family Member or Friend

Ride Share (Uber, Lyft, etc)

Bus

Taxi

Other (please specify)

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* 8. Do you need help finding a ride to work?

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* 9. How many days do you want to work?

1 day

2 - 3 days

4 - 5 days

Other (please specify)

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* 10. How many hours do you want to work per day?

under 4 hours per day

5 - 8 hours per day

Other (please specify)

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* 11. Do you have a Job Developer / Coach?

Yes

If yes, which agency?

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* 12. Are you connected to Opportunities for Ohioans with Disabilities (OOD), the Kentucky Office of Vocation Rehabilitation, or another state agency (IN)?

Yes

If yes, which agency provider are you working with?

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* 13. Do you have a state waiver?

Yes

If yes, which kind?

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* 14. Do you have a resume or an employment profile document?

Yes

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* 15. Would you like a job that regularly uses money (including making change) or math?

Yes

Other (please specify)

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* 16. Would you like a job that required reading and writing?

Yes

Other (please specify)

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* 17. How frequently do you use a computer?

Always

Usually

Sometimes

Rarely

Never

If you do use a computer, what do you use it for? (ie: email, word documents, internet, video games, etc)

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* 18. Do you use a cell phone?

Yes

Other (please specify)

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* 19. Do you have any specific adaptations or accommodations needed to perform a job? (large font, step stool, sensory triggers, etc)

Yes

If yes, please list.

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* 20. Can you stand for periods of time?

Yes

If yes, how long?

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* 21. Can you lift and carry 15 pounds?

Yes

Other (please specify)

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* 22. Do you like working with customers?

Yes

Other (please specify)

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* 23. I am happiest when I am....

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* 24. My biggest strengths are....

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* 25. My ideal job environment would be...

Highly social with people

Alone and able to focus

Something new every day

A set routine

Other (please specify)

DSAGC Employment Questionnaire

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* 1. First and Last Name

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* 2. Email Address

Question Title

* 3. Have you ever been employed?

Question Title

* 4. Are you currently employed?

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* 5. Do you have a ride to work?

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* 6. How far from home are you willing to travel for work?

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* 7. How would you get to work?

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* 8. Do you need help finding a ride to work?

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* 9. How many days do you want to work?

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* 10. How many hours do you want to work per day?

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* 11. Do you have a Job Developer / Coach?

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* 12. Are you connected to Opportunities for Ohioans with Disabilities (OOD), the Kentucky Office of Vocation Rehabilitation, or another state agency (IN)?

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* 13. Do you have a state waiver?

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* 14. Do you have a resume or an employment profile document?

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* 15. Would you like a job that regularly uses money (including making change) or math?

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* 16. Would you like a job that required reading and writing?

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* 17. How frequently do you use a computer?

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* 18. Do you use a cell phone?

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* 19. Do you have any specific adaptations or accommodations needed to perform a job? (large font, step stool, sensory triggers, etc)

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* 20. Can you stand for periods of time?

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* 21. Can you lift and carry 15 pounds?

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* 22. Do you like working with customers?

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* 23. I am happiest when I am....

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* 24. My biggest strengths are....

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* 25. My ideal job environment would be...

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* 26. What else should we know about you?