Employment Services Evaluation Form

First Name

Last Name

Phone

Zip Code

What is your relationship to epilepsy?

I have epilepsy/seizuresMy child has epilepsy/seizuresMy parent has epilepsy/seizuresMy spouse or partner has epilepsy/seizuresAnother family member has epilepsy/seizuresA friend/co-worker has epilepsy/seizuresI work with people who have epilepsy/seizuresOther/prefer not to respond

Employment Services Evaluation

Date of Contact:

	Agree	Somewhat Agree	Neutral	Somewhat Disagree	Disagree
I have an increased understanding of employment resources available to me.
I feel better equipped to request accommodations from my employer, if needed.
I have the necessary tools to discuss epilepsy and seizures with my employer.
I learned more about my rights as an employee with epilepsy.

I was provided the information/resources I needed.

YesNo

Please explain your answer above.

Please select the topics/resources you would like to learn more about in the future:

Please list topics/resources you would be interested in learning more about:

How did you hear about Employment Services?

Please specify:

Contact Information

Connect Groups

Connect Groups are an easy way to meet people affected by epilepsy and share experiences in a safe and supportive environment. The structure and intent of Connect Groups vary by location to meet the needs of that community.

More Information