Are you a domestic worker in Philly? Thanks for starting on our survey! We would love to stay in touch with you. If you would like to get updates on what domestic workers are doing in Philly, please enter your name and phone number. You'll also be entered to win a $50 gift card! OK Question Title * 1. Name: OK Question Title * 2. Phone number: OK Question Title * 3. Country of origin: OK Question Title * 4. Zip code: OK Question Title * 5. How many years have you done domestic work in the US? OK Question Title * 6. In the past month, how were you employed in someone else’s home? Housecleaning Taking care of a child Taking care of an older person Taking care of someone with a disability Other (please specify) OK Question Title * 7. Who pays you for your work? A member of the family you work for The agency/company that sent you to the job Another domestic worker The government Other (please specify) OK Question Title * 8. Do you have a written contract with your employer? Yes No OK Question Title * 9. In the past 12 months, have you received any of the following from your work as a domestic worker? Please check all that apply. Paid time off when you were sick Paid time off when you took a vacation Paid time off for a national holiday Paid overtime (time and a half) when you work more than 40 hours in a work week OK Question Title * 10. In the past 12 months, have you experienced the following? Please check all that apply. Paid less than agreed to, or not at all, for work completed Paid late Paid with a bad check Pressured to work more than your scheduled hours Asked to do work different from what you were hired to do Charged for something that was broken or lost Deductions from your pay without your permission OK Question Title * 11. If you answered yes to any of the above, did you file a complaint with a government agency to enforce your rights? Yes No OK Question Title * 12. What workplace issues concern you most? Please check all that apply. Low wages Non-payment of wages Workplace injuries or health and safety issues Fear of being reported to police or immigration authorities No paid vacation or sick days Lack of job skills and training No health insurance Immigration status Lack of savings/retirement Other (please specify) OK Question Title * 13. In the past 12 months, has an employer, or anyone in an employer’s home, ever done any of the following to you? Please check all that apply. Yelled at you Threatened you Threatened to report you to immigration authorities Kept your passport, visa, or other immigration papers Pushed you or physically hurt you Sexually assaulted or harassed you OK Question Title * 14. Have you ever been injured while at work? Yes No OK Question Title * 15. Have you ever complained to an employer about working conditions on the job? Yes No OK Question Title * 16. If no, what stopped you from complaining? Please check all that apply. Afraid I would lose my job Afraid my pay or hours would be cut Afraid because of my immigration status Fear of violence Didn’t think it would make a difference Needed employer as a reference Other (please specify) OK Question Title * 17. Other issues we should know about? OK Question Title * 18. YES! I want to work with the Pennsylvania Domestic Workers Alliance to win better treatment of domestic workers in Pennsylvania by... (Please check all that apply) Attending gatherings with other domestic workers to make friends, develop leadership skills, win better laws to protect us at work Invite other domestic workers you know to get involved to win Learning about your rights as a domestic worker Learning about how to negotiate a contract and improve communication with your employer Learning CPR Learning how to use and make less toxic cleaning products Learning self-defense against harassment and sexual assault Learning workplace English Other (please specify) OK DONE