New Applicant Survey
*
1.
Would you like assistance with job search or employment placement?
(Required.)
YES
NO
2.
Are you interested in enrolling in career training classes?
Yes
No
3.
Are you over 65 and need assistance with daily living activities such as meals, laundry and housekeeping?
Yes
No
4.
Do you have anyone in your household between the ages of 16 and 24 who dropped out of high school at any time?
Yes
No
5.
If you are under the age of 64 and receiving SSI or SSDI benefits, are you interested in going to work?
NO, I am not receiving SSI/SSDI benefits
YES, I am receiving SSI/SSDI benefits and would like to go to work
NO, I am not interested in going to work while receiving my SSI/SSDI benefits