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    PEP Jobs Program Participant Questionnaire

    If you are interested in participating in this program please fill it out and print the program questionnaire PDF, then fax it to us at 415-600-4879.

    Print PDF file of the PEP Jobs Program Participant Questionnaire

    If you are unable to use the PDF questionnaire, please write or type on plain paper the information requested below, then fax it to us at 415-600-4879.

    General Information

    • Name:
    • Street address:
    • City:
    • State:
    • Zip:
    • Home phone:
    • Cell phone / other phone:
    • E-mail:
    • Are you over 18 years old?
    • Highest Education Level:
    • Disabilities and Health Conditions:
    • History of alcohol and/or substance abuse?
      • If yes, length of sobriety “clean time”:
    • Functional limitations (activities you cannot do):
    • Have you ever been convicted of a felony?
      • If yes, please give details:
    • 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:

    Please sign and date your questionnaire before you fax it to us.

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