Disability Program - Work Activity Survey Please keep in mind the information that you provide during this survey is CONFIDENTIAL. Please be aware that your opinion and responses are very important to help improve the program. Thank you. Question Title * 1. I get along with my Job Coach. Yes No Other (please specify) Question Title * 2. I feel happy when I am at work. Yes No Other (please specify) Question Title * 3. I feel safe at work. Yes No Other (please specify) Question Title * 4. I like my job. Yes No Other (please specify) Question Title * 5. If you have a choice, would you like to: Keep the job the way it is Make changes to the job Get a different job Other (please specify) Question Title * 6. How likely are you to recommend this program to others? 1 2 3 4 5 6 7 8 9 10 Please rate on a scale of 1 to 10, with 10 being the most likely to refer others. Please rate on a scale of 1 to 10, with 10 being the most likely to refer others. 1 Please rate on a scale of 1 to 10, with 10 being the most likely to refer others. 2 Please rate on a scale of 1 to 10, with 10 being the most likely to refer others. 3 Please rate on a scale of 1 to 10, with 10 being the most likely to refer others. 4 Please rate on a scale of 1 to 10, with 10 being the most likely to refer others. 5 Please rate on a scale of 1 to 10, with 10 being the most likely to refer others. 6 Please rate on a scale of 1 to 10, with 10 being the most likely to refer others. 7 Please rate on a scale of 1 to 10, with 10 being the most likely to refer others. 8 Please rate on a scale of 1 to 10, with 10 being the most likely to refer others. 9 Please rate on a scale of 1 to 10, with 10 being the most likely to refer others. 10 Done
