PEP Jobs Program Participant Questionnaire
If you are interested in participating in this program please complete the program questionnaire below and fax it to us at 415-600-7479.
Printer-friendly option: PDF file of the PEP Jobs Program Participant Questionnaire (26KB)
General Information
Name:
Street address:
City:
State:
Zip:
Home phone:
Cell phone / other phone:
E-mail:
Are you over 18 years old?
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Disabilities and Health Conditions
History of alcohol and/or substance abuse?
If yes, length of sobriety “clean time”:
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Highest Education Level
Functional limitations (activities you cannot do):
Have you ever been convicted of a felony?
If yes, please give details:
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Type of Seizures you Experience
When do your seizures usually happen and how often?
Do you get a warning before a seizure?
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Work Interests
Type of work most interested in:
How many full-time jobs have you had in the last 3 years? Part-time?
How long were you employed for at your last 2 employers?
Would you like to work full-time, part-time or either?
What are your financial goals? –or– How much money would you like to make?
What did you like most about your previous jobs?
What did you like least?
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Emergency Information
Who should be contacted in case of emergency?
Name:
Address:
Home phone:
Cell phone:
________________________________________
Participant Signature Date
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