SEIU UHW-West & Joint Employer Education Fund LTC Survey

LONG TERM CARE Educational Interest Survey
To be eligible to apply for Education Fund programs and services you must:

Be an SEIU member working in a bargaining unit position for which the employer makes an Education Fund contribution.

Be a regular full- or part-time employee eligible for benefits.

Have completed your probationary period with your employer.

Meet other eligibility criteria set by the Education Fund, your employer and/or your selected college.

Name				Date
Employer1		Facility1		City
Job Classification		Shift	#Hours Worked/Week	Eligible for Benefits? Yes No
Employer #2		Facility		City
Job Classification		Shift	#Hours Worked/Week	Eligible for Benefits? Yes No
Work Phone	Cell Phone	Home Phone	Email
1. Do you have a long range career goal in healthcare? Yes No If yes, what?
2. Tell us about your educational background. This information will not be share with your employer. We will use is to better understand what kind of classes to offer. I have completed the following (check the highest level):
Grade School (highest grade completed: )		High School Diploma or GED
Technical Training		Some college classes but no degree
Associate Degree (two-year college)		Bachelor's Degree (four-year college)
3. Are you currently in a health related training program or taking college courses? Yes No If yes, what program/school?
4. Does anything stand in the way of you going back to school (i.e. childcare, transportation, work, etc)?: Yes No If yes, please explain:
5. Does your current job require Continuing Education Units (CEU's)? Yes No If yes, what kinds of programs are you interested in?
6. Which of the following classes/programs would you take if they were offered in your area? (Select all that apply)
7. Would you be interested in training to become a CNA? Yes No
8. Would you be interested in a CNA to LVN program? Yes No
9. Would you be interested in an RN program? Yes No
Comments :

Submit button will email your responses to us. We will contact you if we have additional questions or need more information. Thank you for your time and your interest in the Education Fund. We look forward to working with you.