Exhibit_C_-_Self-Employment_Readiness_Questionnaire.pdf

Page 1 of 3VR-1010A FORFF (9-21) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Rehabilitation Services Administration, Vocational Rehabilitation (VR) Program

SELF-EMPLOYMENT GUIDE

PART 2: SELF-EMPLOYMENT READINESS QUESTIONNAIRE

Client’s Name:

VR Counselor’s Name: Date of completion:

This questionnaire is intended to help you and your VR counselor evaluate your readiness for operating a business.

Please answer every question.

What are your priorities related to work (e.g., part time/full time work, earnings level, benefit expectations, flexibility, independence, etc.)? Briefly describe:

Why do you think it is better to operate a business than to work as an employee? Briefly describe:

Why do you think you are ready to start a business? Briefly describe:

What skills do you have that are necessary for running a business? Give example (s):

Will your disability pose barriers to operating this business? If yes, what are they? How do you plan to overcome or address these barriers? Briefly describe:

Do you have the physical stamina to start a small business and sustain business operations and management? If yes, how do you plan to address this barrier? Briefly describe:

See page 2 for USDA/EOE/ADA disclosures

Page 2 of 3VR-1010A FORFF (9-21)

Do you need any accommodations for your disability? Briefly describe:

Are you concerned with the impact of earnings on SSI or SSDI? Briefly describe:

Is there anything that would prevent you from obtaining the required certifications or licenses (criminal history, outstanding child support, owes taxes, outstanding loans, revoked license, etc.)? Briefly describe:

How are your basic needs being met now (food, shelter, clothing)? Briefly describe:

Will your personal finances allow you to pursue starting and operating a business? Briefly describe:

What supports do you have to assist you with the business (family, friends, community support)? What type of assistance will your supports provide? Briefly describe:

Page 3 of 3VR-1010A FORFF (9-21)

SUPPLEMENTAL INFORMATION

Client Signature: Date:

VR Counselor Signature: Date:

Contractor Signature: Date:

Equal Opportunity Employer / Program • Auxiliary aids and services are available upon request to individuals with disabilities • To request this document in alternative format or for further information about this policy, contact your local RSA office; TTY/TDD Services: 7-1-1