## Ac **cess to Telew ork Programs** 

**Data Collection Instrument and Instructions**

**One Year Follow -**  **up Data** At the one - ye ar anniversary of the loan, use this survey form to ask follow - up questions to the Direct Users who have had their loan for one y ear. The survey will allow y ou to report on whether Direct Users’ primary employ ment goals at the time of loan closings were achieved one ye ar later as a result of a Telework loan. Telework Programs may

collect this follow - up data in a manner that best meets their nee ds. The data from the Direct Users may be collected in person, via phone, via mail, or online. Regardless of the method of data collection, programs should collect the data from the Direct User as near as possible to the 12 - month anniversary of the loan’ s closing. To produce valid data, you should try to obtain as high a response rate as possible. **To be completed by Telework program staff:** Employ ment status at time of application: ____ Unemploy ed ____ Self - employ ed ____ Employ ed ____ Employ ed and Self - employ ed Primary employ ment goal at time of application was to: ____ become newly

employ ed in telework for an employ er. ____ become newly

self - employ ed. ____ change to teleworking job for an emplo yer. ____ change to s elf

- employ ment job. ____ expand existing business. ____ other, brief description: Please answer the following questions about the loan that you received from (insert name of Telework Loan Program). **1. Since receiving your Telework loan one year ago, have you achieved your primary employment goal?**  **(Please mark only one answer.)** YES, Iachieved my

primary employ ment goal:
____ I have become newly employ ed in telework for an emplo ye r. (I did not have a job and now I do have a job.)
____ I have become newly self - employ ed. (I did not have a job and now I work for my self.)
____ I changed to a teleworking job for an emplo yer. (I had a job but I changedjob/kind of work.)
____ I changed to a self

- employ ment job. (I had a job but now Iwork for my self.)
____ I expanded my

business.
____ I had another goal. Brief description: _____ NO, but I changed my employ ment goal and achieved it.

__ ___ NO, I did not achieve my primary employment goal. **2. If you achieved your employment goal, please answer the following:** Did y our wages/salary

increase? ____ YES ____ NO Were y ou able to maintain y our employ ment? ____ YES ____ NO
Acco rding to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 1 0 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is requ ired to obtain or retain benefits (34 CFR 75.720; Notice of Final Priority for the Access to Telework Program (68 FR 56274)). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reduc ing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210 - 4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1820 - 0687. Note: Please do not return the comp leted Annual Report for Access to Telework Programs (Telework) Data Collection Instrument and Instructions application to this address.