1. Did you work last week? 
  Yes No

If you answered yes to #1
1a. Was this a regular job   Yes No
1b. Were you working fewer than the number of hours you wanted to work?  Yes No
1c. Does the job have benefits, such as health insurance & paid time off?  Yes No

2. How long have you been unemployed
3 months or less 3-6 months 6 months or more

3. What did you do at your last regular job?


If still unemployed, please answer the following questions:

4. How confident are you that you will find a new regular job in the next two months? Not Confident Just Fairly Confident Somewhat Confident Very Confident

5. Are you thinking of doing because you have not been able to find a regular job
Switching Careers Entering Training/Going Back to School Taking a job that pays significantly less than my last one Dropping out of the job market: Retiring/Staying Home With Kids

All respondents:

6. Compared to the beginning of the year, do you think finding a job now is:
Much Easier Significantly Easier Just somewhat easier Not Easier

7. Since you lost your last regular job, have you taken part-time work or done free-lance work when you would prefer full-time, stable employment?
Yes No

8. Which of the following hardships have you experienced while unemployed:

a. Increased Personal or Family Stress
. Yes No

b Declared Bankruptcy 
Yes No
 
c. Drained Retirement Savings
Yes No Doesn't apply to me

d. Increased Credit Card or Household Debt
Yes No

e. Been forced to move
Yes No

f. Cut back on spending for your kids  
Yes No Doesn't apply to me

g. Cutting back on spending for food   
Yes No

h. Losing health insurance for you or your family 
Yes No

i. Postpoing or not accessing health or medical treatment 
Yes No Doesn't apply to me

9. I’ve run out of unemployment benefits, and need an extension. 
Yes No

10. If I got an extended unemployment benefits check, the most important thing I’d use it for would be to (Pick one)

Pay back debt/Avoid bankruptcy Pay rent or housing expense Pay for basics: food, clothing, etc. Stop dipping further into savings Pay for job search expenses or job training

 Other 

11. OPTIONAL, SHARE YOUR STORY: In your own words answer the following questions: “What makes it hard for you to find a good job today? What has been the impact of your unemployment on your family? What should government do differently to help the unemployed get back to work?”

12. - Would you be willing to share your story with others?
Yes No