1. Your job/industry
2. Are you a member of a union? Yes No     If so,what union
3. Do you have paid sick days? Yes No
4. If so, how many paid sick days can you take a year?
5. Can you take a paid sick day to care for a family member? Yes No
6. Can you use a paid sick day for medical appointments? Yes No
7. How many sick days do you usually take in a year?
8. Have you ever gone to work sick because you didn’t have paid sick days? Yes No
9. Have you ever gone to work sick because you lack paid sick days? Yes No
10. Have you ever sent your kids to school sick because you lack paid sick days? Yes No
11. Have you ever been unable to care for a sick family member because you lack paid sick days? Yes No
12. Have any of the following happened when you called in sick?
Loss of pay Loss of job Reduced hours or shifts Disciplined      Other
13. Have you ever put off a doctor visit for you or your child because you had no paid sick days? Yes No
14. Has going to work sick ever made your illness worse? Yes No

15. Ethnicity
16. Age
17. Gender
18. Marital Status
19. I am responsible for caring for (check all that apply) child parent    Other

20. Name
21. Email
22. Phone Number