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* 1. Name:

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* 2. Phone number:

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* 3. Country of origin:

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* 4. Zip code:

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* 5. How many years have you done domestic work in the US?

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* 6. In the past month, how were you employed in someone else’s home?

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* 7. Who pays you for your work?

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* 8. Do you have a written contract with your employer?

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* 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.

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* 10. In the past 12 months, have you experienced the following? Please check all that apply.

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* 11. If you answered yes to any of the above, did you file a complaint with a government agency to enforce your rights?

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* 12. What workplace issues concern you most? Please check all that apply.

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* 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.

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* 14. Have you ever been injured while at work?

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* 15. Have you ever complained to an employer about working conditions on the job?

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* 16. If no, what stopped you from complaining? Please check all that apply.

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* 17. Other issues we should know about?

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* 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)

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