Disability Employment Initiative

The following instructions apply to the Disability Employment Initiative (DEI) section of the Demographics Information. For this page, the type of field is identified, as well as the description for each field.

1. Activities of Daily Living: Check boxes; Select all that apply:
   • I need encouragement to attend to my daily activities.
   • I need help finding a job and returning to work.
   • I need help remembering to attend to my daily activities and chores, such as preparing meals.
   • I take care of others.
   • My disability affects my ability to dress myself.
   • My disability affects my ability to drive a car.
   • My disability affects my ability to go shopping.
   • My disability affects my ability to prepare and consume food.
2. Disability Type: Check boxes; Select all that apply:
   • Attention-Deficit/Hyperactivity Disorders
   • Brain Injuries
   • HIV/AIDS
   • Medical Disabilities (e.g., muscular sclerosis)
   • Mental Retardation
   • Recovering Substance Abuse
   • Seizure
   • Speech and Language Disabilities

   Based on your perceptions, which of the following things do you think will make it hard for you to get a job? (Please select all that apply)

3. Limited education or training: Drop-down; select Yes, No, or Unknown.
4. Limited work history/experience: Drop-down; select Yes, No, or Unknown.
5. No child care: Drop-down; select Yes, No, or Unknown.
6. Substance abuse: Drop-down; select Yes, No, or Unknown.
7. Limited transportation:Drop-down; select Yes, No, or Unknown. 
8. Language barrier: Drop-down; select Yes, No, or Unknown.
9. Ex-Offender: Drop-down; select Yes, No, or Unknown.
10. Housing/homeless: Drop-down; select Yes, No, or Unknown.
11. Disability: Drop-down; select Yes, No, or Unknown.
12. Start Date of Most Recent Employment: Text/Calendar: enter that start date of the client's most recent employment in mm/dd/yyyy format.
13. Most Recent Job Title: Text; enter the client's most recent job title.
14. Hourly Wage of Most Recent Job: Text; enter the hourly wage of the client's most recent job.
15. Hours Worked Per Week In Most Recent Job: Text; enter the number of hours worked per week at the client's most recent job.
16. Benefits Offered: Checkbox; select the benefits offered at the client's most recent job. Select all that apply:
    • Health Insurance
    • Vacation
    • Sick Leave
    • Flexible Hours
    • Work From Home
    • Customized Employment
    • Job Sharing
    • None
17. How Often is Contact Made with Family and Close Friends: Drop-down; required field for youth under the age of 22. Select from:
    • Daily
    • Weekly
    • Monthly
    • Less Than Monthly.
18. Current Living Situation: Drop-down; required field for youth under the age of 22. Select from:
    • By Myself
    • Family
    • Foster Family
    • Friend
    • Group Home
    • Shelter/Other