🚀 go-pugleaf

The following is a questionnaire for individuals diagnosed HIV positive or
with AIDS related illnesses.  The results will be used in a study of the
needs and barriers to employment for a graduate program thesis.  If you are
an individual that has received HIV positive results or are experiencing
AIDS related illness, please answer all questions and return to the author
by March 16, 1998.  Also, please only respond once to the survey.
There will be no attempt to identify any respondants and
no further contact will be made.  Your time and input is valuable to this
study.
STATUS QUESTIONNAIRE
Date completed ____________. What is your date of birth? ______________.
What date were you diagnosed HIV? ___________. Male ____ Female _____.
Anglo ___ Hispanic ___ Black ___ Native American ___ Asian ___Other _____.
Did you graduate from high school?  Yes ____ No ____ Year ________.
What other education or training have you had? (Mark all that apply).
Vocational/Technical Training: ______________________________.
Completed training?  Yes ______    No ______.
College: Yes _____ No ___.
Graduated?  Yes ______    No ______ Year Completed: _______.
Degree Earned: __________________________________________.
How many years did you work prior to your diagnosis? _________________.
Are you currently working?  Yes ______    No ______.
   Full-time ______    Part-time ______.
Your primary occupation? ________________________________________.
Are you or were you self-employed? ________________________________.
Your average yearly earnings while working? _________________________.
Are you attending any training programs now?  Yes ______    No ______.
Have you applied for the State Division of Vocational Rehabilitation
Services?
Yes ______    No ______.
If so, did you receive services?  Yes ______    No ______.
If yes, what services? ______________________________________________.
If no, why not? ___________________________________________________.
What financial supports are you currently receiving? (Mark all that apply).
______ Social Security Disability (SSDI-B).
______ Supplemental Security Income (SSI).
______ Public Health Insurance.
______ Food Stamps.
______ Assistance from your family.
______ Private Insurance Disability Income.
______ Retirement Income from working.
______ Housing
______ State Family Assistance
______ State Funded Child Care
______ Other, please list: ___________________________________________.
Do you need any assistance in other areas? (Mark all that apply).
______ Housing   ______ Transportation
______ Mental Health  ______ Food
______ Medical care  ______ Physical Therapy
______ Vocational   ______ Housekeeping services
______ Other, please list: ___________________________________________.
If you are not working and would like to return to work, what are the
barriers? (Mark all that apply).
______ Medication costs   ______ Poor consistent functioning
______ Medical costs   ______ Easily fatigued
______ Uncertainty of maintaining functioning over time
______ Physically deconditioned  ______ Fear of rejection (prejudices)
______ Need training   ______ Need assist with job placement
______ No transportation   ______ Loss of financial supports
______ Insurance coverage  ______ Unable to work full-time
______ Other, please list: ___________________________________________.
Thank you for your time and input.  Please return in the envelope provided
to you by March 16, 1998.