Work Well Interest Survey Question Title * 1. Personal Information. Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Question Title * 2. Which of the following best describes your current relationship status? Married Widowed Divorced Separated Cohabiting with a significant other or in a domestic partnership Single, never married Prefer not to answer Question Title * 3. Do you own a laptop or iPad? (a device other than your smartphone?) Yes No Question Title * 4. After completing Work Well Soft Skills training, which certification program would you like to attend? EKG Technician Phlebotomy Certification Question Title * 5. FOR DEC. 1 ATTENDEES ONLY! Will you need a ride to & from the EKG Training on Dec. 9 & 10? Yes No Question Title * 6. Please select your geographic area. Five Points West Ensley Smithfield/Elyton Other (please specify) Question Title * 7. Race or ethnicity. White or Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race Question Title * 8. Age. Under 18 18-24 25-35 Question Title * 9. What is your gender? Female Male Non-binary Question Title * 10. What is the highest level of school you have completed or the highest degree you have received? Less than high school degree High school degree or equivalent (e.g., GED) Some college but no degree Associate degree Bachelor degree Graduate degree Question Title * 11. Which of the following best describes your current employment status? Employed, working 1-39 hours/wk Employed, working 40 or more hours/wk Not employed, seeking employment Disabled, looking for work with accommodations Question Title * 12. If Employed, what is your hourly wage? 0 - $10 $11 - $20 $21 and up Question Title * 13. What is the best way to contact you? Phone Email Text Mail Submit
