J
jcontrer
I'm a languge coordiantor in a hospital. so i manage the hospital's language
resources. we use our own employees as interpreters so i have to get the
information from them regarding what languages they speak. I've found that
the current method of using paper surveys is not efficient and i wanted to
know if there is something else i could be using.
I would like to make a survey that i could e-mail to each individual
employee or post on the hospital employee website. and then have those
results from the survey put into an access spreadsheet where i can analyze
and make changes.
In case you want to see, the survey looks like this in HTML (i used word web
form):
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<span style='font-size:12.0pt'>Bi-Lingual Employee Language Skills
Survey<o></o></span></p>
<p class=MsoTitle style='margin-right:119.25pt;tab-stops:564.0pt'><span
style='font-size:12.0pt'><o> </o></span></p>
<form>
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5.4pt;height:39.0pt'>
<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'>FOREIGN<span
style='text-transform:uppercase'>
Languages In Which You Are Fluent (Including ASL)<o></o></span></b></p>
</td>
<td width=560 valign=top style='width:420.0pt;border:solid windowtext 1.0pt;
border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:39.0pt'>
<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'>How
Did You Acquire This Foreign Language?<o></o></span></b></p>
<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'><o> </o></span></b></p>
<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'>(Check
Those Boxes Which Apply to You)<o></o></span></b></p>
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<p class=MsoNormal>1)</p>
<p class=MsoNormal><o> </o></p>
<p class=MsoNormal><o> </o></p>
<p class=MsoNormal><o> </o></p>
<p class=MsoNormal><o> </o></p>
<p class=MsoNormal><INPUT TYPE="TEXT" SIZE="30"
NAME="Foreignlanguage#1"></p>
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<p class=MsoNormal style='margin-left:12.0pt;text-indent:-12.0pt'><span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX" NAME="lang#1
fluent 1"><b
style='mso-bidi-font-weight:normal'>After the age of ten</b>, I lived for at
least <b style='mso-bidi-font-weight:normal'>five</b> consecutive years in a
region, state or country where this language is the primary language.</p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:50%'><o> </o></p>
<p class=MsoNormal style='margin-left:12.0pt;text-indent:-12.0pt'><span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX" NAME="lang#2
fluent 2">I
completed a <b style='mso-bidi-font-weight:normal'>high school,
undergraduate,
or graduate degree</b> from an institution whose primary instructional
language is this language.</p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:50%'><o> </o></p>
<p class=MsoNormal style='margin-left:12.0pt;text-indent:-12.0pt'><span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX" NAME="lang#1
other">Other:
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<p class=MsoNormal>2)</p>
<p class=MsoNormal><o> </o></p>
<p class=MsoNormal><o> </o></p>
<p class=MsoNormal><o> </o></p>
<p class=MsoNormal><o> </o></p>
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NAME="foreignlanguage#2"></p>
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<p class=MsoNormal style='margin-left:12.0pt;text-indent:-12.0pt'><span
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style='mso-bidi-font-weight:normal'>After the age of ten</b>, I lived for at
least <b style='mso-bidi-font-weight:normal'>five</b> consecutive years in a
region, state or country where this language is the primary language.</p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:50%'><o> </o></p>
<p class=MsoNormal style='margin-left:12.0pt;text-indent:-12.0pt'><span
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v:shapes="_x0000_i1049"><![endif]>I
completed a <b style='mso-bidi-font-weight:normal'>high</b> <b
style='mso-bidi-font-weight:normal'>school, undergraduate, or graduate
degree</b>
from an institution whose primary instructional language is this
language.</p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:50%'><o> </o></p>
<p class=MsoNormal style='margin-top:0in;margin-right:-5.0pt;margin-bottom:
0in;margin-left:12.0pt;margin-bottom:.0001pt;text-indent:-12.0pt'><span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX" NAME="lang#2
other">Other:
<INPUT TYPE="TEXT" SIZE="92"></p>
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<td width=184 valign=top style='width:138.2pt;border:solid windowtext 1.0pt;
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..5pt;mso-border-alt:solid windowtext .5pt;
padding:0in 5.4pt 0in 5.4pt;height:164.0pt'>
<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'>Do
You Have Knowledge of Medical Terminology in a foreign
Language?<o></o></span></b></p>
<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'><o> </o></span></b></p>
<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'>Which
languages?<o></o></span></b></p>
<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'><!--[if gte vml 1]><v:shape
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<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'>----------------------------------<o></o></span></b></p>
<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'><INPUT TYPE="TEXT" SIZE="26" NAME="language
medterm #2"><span
style='mso-spacerun:yes'> </span><o></o></span></b></p>
<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'>----------------------------------<o></o></span></b></p>
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<p class=MsoNormal style='margin-left:12.0pt;text-indent:-12.0pt'><span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX" NAME="med term
yes">YES<span
style='mso-spacerun:yes'>
</span><INPUT TYPE="CHECKBOX" NAME="med term no">NO<span
style='mso-spacerun:yes'>
</span><INPUT TYPE="CHECKBOX" NAME="med term some">Somewhat</p>
<p class=MsoNormal style='line-height:50%'><o> </o></p>
<p class=MsoNormal><b style='mso-bidi-font-weight:normal'><span
style='mso-spacerun:yes'> </span>Please indicate how you acquired this
knowledge. <o></o></b></p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:50%'><o> </o></p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt'><span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX">I attended
medical training/school where the foreign language in which I am fluent was
the primary instructional language.</p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:50%'><o> </o></p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:150%'><span style='mso-spacerun:yes'> </span>Name of
School:<INPUT TYPE="TEXT" SIZE="81" NAME="med school name"></p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:150%'><span style='mso-spacerun:yes'> </span>Dates
attended<span style='mso-spacerun:yes'> </span>From: Yr.<INPUT
TYPE="TEXT">
To: Yr.<INPUT TYPE="TEXT"></p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt'><INPUT
TYPE="CHECKBOX">Other:<INPUT TYPE="TEXT" SIZE="94"></p>
</td>
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<td width=744 colspan=2 valign=top style='width:558.2pt;border:solid
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..5pt;mso-border-alt:solid windowtext .5pt;
padding:0in 5.4pt 0in 5.4pt;height:69.6pt'>
<p class=MsoNormal>If I meet the qualifications to be an interpreter (which
may require that my proficiency in the language and/or Medical Terminology
be
assessed), you may list my name in the <st1lace w:st="on"><st1laceName
w:st="on">Medical</st1laceName> <st1laceType
w:st="on">Center</st1laceType></st1lace>’s
Language Bank:</p>
<p class=MsoNormal align=center style='text-align:center'><INPUT
TYPE="CHECKBOX" NAME="Lang Bank Yes">YES<span
style='mso-spacerun:yes'>
</span><INPUT TYPE="CHECKBOX" NAME="lang bank No">NO</p>
<p class=MsoNormal><b style='mso-bidi-font-weight:normal'>If Yes: </b>Are
you
interested in attending <span style='text-transform:uppercase'>Certified
Medical Interpreter</span> classes?<span style='mso-spacerun:yes'>
</span>(Classes are Free and are scheduled during work hours)<span
style='mso-spacerun:yes'>
</span><INPUT TYPE="CHECKBOX" NAME="classes yes">Yes<span
style='mso-spacerun:yes'>
</span><INPUT TYPE="CHECKBOX" NAME="classes no">No</p>
<p class=MsoNormal>Have you taken the NYU Language Assessment?<span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX">Yes<span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX">No</p>
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<p class=MsoNormal style='margin-left:1.0in;text-indent:.5in'>(LAST)<span
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<p class=MsoNormal>Signature: _________________________________<span
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<p class=MsoNormal><o> </o></p>
</form>
</div>
</body>
</html>
resources. we use our own employees as interpreters so i have to get the
information from them regarding what languages they speak. I've found that
the current method of using paper surveys is not efficient and i wanted to
know if there is something else i could be using.
I would like to make a survey that i could e-mail to each individual
employee or post on the hospital employee website. and then have those
results from the survey put into an access spreadsheet where i can analyze
and make changes.
In case you want to see, the survey looks like this in HTML (i used word web
form):
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<![endif]><![endif]--><![if !vml]><span style='mso-ignore:vglayout;position:
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1]></o:wrapblock><![endif]--><br
style='mso-ignore:vglayout' clear=ALL>
<span style='font-size:12.0pt'>Bi-Lingual Employee Language Skills
Survey<o
></o></span></p><p class=MsoTitle style='margin-right:119.25pt;tab-stops:564.0pt'><span
style='font-size:12.0pt'><o
> </o></span></p><form>
<table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 width=744
style='width:558.2pt;margin-left:5.4pt;border-collapse:collapse;border:none;
mso-border-alt:solid windowtext .5pt;mso-yfti-tbllook:480;mso-padding-alt:
0in 5.4pt 0in 5.4pt;mso-border-insideh:.5pt solid
windowtext;mso-border-insidev:
.5pt solid windowtext'>
<tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;height:39.0pt'>
<td width=184 valign=top style='width:138.2pt;border:solid windowtext 1.0pt;
mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in
5.4pt;height:39.0pt'>
<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'>FOREIGN<span
style='text-transform:uppercase'>
Languages In Which You Are Fluent (Including ASL)<o
></o></span></b></p></td>
<td width=560 valign=top style='width:420.0pt;border:solid windowtext 1.0pt;
border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:39.0pt'>
<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'>How
Did You Acquire This Foreign Language?<o
></o></span></b></p><p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'><o
> </o></span></b></p><p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'>(Check
Those Boxes Which Apply to You)<o
></o></span></b></p></td>
</tr>
<tr style='mso-yfti-irow:1;height:82.55pt'>
<td width=184 valign=top style='width:138.2pt;border:solid windowtext 1.0pt;
border-top:none;mso-border-top-alt:solid windowtext
..5pt;mso-border-alt:solid windowtext .5pt;
padding:0in 5.4pt 0in 5.4pt;height:82.55pt'>
<p class=MsoNormal>1)</p>
<p class=MsoNormal><o
> </o></p><p class=MsoNormal><o
> </o></p><p class=MsoNormal><o
> </o></p><p class=MsoNormal><o
> </o></p><p class=MsoNormal><INPUT TYPE="TEXT" SIZE="30"
NAME="Foreignlanguage#1"></p>
</td>
<td width=560 valign=top style='width:420.0pt;border-top:none;border-left:
none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext
1.0pt;
mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid
windowtext .5pt;
mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in
5.4pt;height:82.55pt'>
<p class=MsoNormal style='margin-left:12.0pt;text-indent:-12.0pt'><span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX" NAME="lang#1
fluent 1"><b
style='mso-bidi-font-weight:normal'>After the age of ten</b>, I lived for at
least <b style='mso-bidi-font-weight:normal'>five</b> consecutive years in a
region, state or country where this language is the primary language.</p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:50%'><o
> </o></p><p class=MsoNormal style='margin-left:12.0pt;text-indent:-12.0pt'><span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX" NAME="lang#2
fluent 2">I
completed a <b style='mso-bidi-font-weight:normal'>high school,
undergraduate,
or graduate degree</b> from an institution whose primary instructional
language is this language.</p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:50%'><o
> </o></p><p class=MsoNormal style='margin-left:12.0pt;text-indent:-12.0pt'><span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX" NAME="lang#1
other">Other:
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v:shapes="_x0000_i1058"><![endif]></p>
</td>
</tr>
<tr style='mso-yfti-irow:2;height:85.05pt'>
<td width=184 valign=top style='width:138.2pt;border:solid windowtext 1.0pt;
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..5pt;mso-border-alt:solid windowtext .5pt;
padding:0in 5.4pt 0in 5.4pt;height:85.05pt'>
<p class=MsoNormal>2)</p>
<p class=MsoNormal><o
> </o></p><p class=MsoNormal><o
> </o></p><p class=MsoNormal><o
> </o></p><p class=MsoNormal><o
> </o></p><p class=MsoNormal><INPUT TYPE="TEXT" SIZE="30"
NAME="foreignlanguage#2"></p>
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<td width=560 valign=top style='width:420.0pt;border-top:none;border-left:
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1.0pt;
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windowtext .5pt;
mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in
5.4pt;height:85.05pt'>
<p class=MsoNormal style='margin-left:12.0pt;text-indent:-12.0pt'><span
style='mso-spacerun:yes'> </span><!--[if gte vml 1]><v:shape
id="_x0000_i1050"
type="#_x0000_t75" style='width:20.25pt;height:18pt'>
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grayscale="t" bilevel="t"/>
</v:shape><![endif]--><![if !vml]><img width=27 height=24
src="online%20survey%20forms_files/image006.gif"
v:shapes="_x0000_i1050"><![endif]><b
style='mso-bidi-font-weight:normal'>After the age of ten</b>, I lived for at
least <b style='mso-bidi-font-weight:normal'>five</b> consecutive years in a
region, state or country where this language is the primary language.</p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:50%'><o
> </o></p><p class=MsoNormal style='margin-left:12.0pt;text-indent:-12.0pt'><span
style='mso-spacerun:yes'> </span><!--[if gte vml 1]><v:shape
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type="#_x0000_t75" style='width:20.25pt;height:18pt'>
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</v:shape><![endif]--><![if !vml]><img width=27 height=24
src="online%20survey%20forms_files/image006.gif"
v:shapes="_x0000_i1049"><![endif]>I
completed a <b style='mso-bidi-font-weight:normal'>high</b> <b
style='mso-bidi-font-weight:normal'>school, undergraduate, or graduate
degree</b>
from an institution whose primary instructional language is this
language.</p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:50%'><o
> </o></p><p class=MsoNormal style='margin-top:0in;margin-right:-5.0pt;margin-bottom:
0in;margin-left:12.0pt;margin-bottom:.0001pt;text-indent:-12.0pt'><span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX" NAME="lang#2
other">Other:
<INPUT TYPE="TEXT" SIZE="92"></p>
</td>
</tr>
<tr style='mso-yfti-irow:3;height:164.0pt'>
<td width=184 valign=top style='width:138.2pt;border:solid windowtext 1.0pt;
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..5pt;mso-border-alt:solid windowtext .5pt;
padding:0in 5.4pt 0in 5.4pt;height:164.0pt'>
<p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'>Do
You Have Knowledge of Medical Terminology in a foreign
Language?<o
></o></span></b></p><p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'><o
> </o></span></b></p><p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'>Which
languages?<o
></o></span></b></p><p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'><!--[if gte vml 1]><v:shape
id="_x0000_i1048" type="#_x0000_t75" style='width:109.5pt;height:18pt'>
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</v:shape><![endif]--><![if !vml]><img width=146 height=24
src="online%20survey%20forms_files/image008.gif"
v:shapes="_x0000_i1048"><![endif]><o
></o></span></b></p><p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'>----------------------------------<o
></o></span></b></p><p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'><INPUT TYPE="TEXT" SIZE="26" NAME="language
medterm #2"><span
style='mso-spacerun:yes'> </span><o
></o></span></b></p><p class=MsoNormal align=center style='text-align:center'><b
style='mso-bidi-font-weight:normal'><span
style='text-transform:uppercase'>----------------------------------<o
></o></span></b></p></td>
<td width=560 valign=top style='width:420.0pt;border-top:none;border-left:
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1.0pt;
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mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in
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<p class=MsoNormal style='margin-left:12.0pt;text-indent:-12.0pt'><span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX" NAME="med term
yes">YES<span
style='mso-spacerun:yes'>
</span><INPUT TYPE="CHECKBOX" NAME="med term no">NO<span
style='mso-spacerun:yes'>
</span><INPUT TYPE="CHECKBOX" NAME="med term some">Somewhat</p>
<p class=MsoNormal style='line-height:50%'><o
> </o></p><p class=MsoNormal><b style='mso-bidi-font-weight:normal'><span
style='mso-spacerun:yes'> </span>Please indicate how you acquired this
knowledge. <o
></o></b></p><p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:50%'><o
> </o></p><p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt'><span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX">I attended
medical training/school where the foreign language in which I am fluent was
the primary instructional language.</p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:50%'><o
> </o></p><p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:150%'><span style='mso-spacerun:yes'> </span>Name of
School:<INPUT TYPE="TEXT" SIZE="81" NAME="med school name"></p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt;
line-height:150%'><span style='mso-spacerun:yes'> </span>Dates
attended<span style='mso-spacerun:yes'> </span>From: Yr.<INPUT
TYPE="TEXT">
To: Yr.<INPUT TYPE="TEXT"></p>
<p class=MsoNormal style='margin-left:12.25pt;text-indent:-12.25pt'><INPUT
TYPE="CHECKBOX">Other:<INPUT TYPE="TEXT" SIZE="94"></p>
</td>
</tr>
<tr style='mso-yfti-irow:4;mso-yfti-lastrow:yes;height:69.6pt'>
<td width=744 colspan=2 valign=top style='width:558.2pt;border:solid
windowtext 1.0pt;
border-top:none;mso-border-top-alt:solid windowtext
..5pt;mso-border-alt:solid windowtext .5pt;
padding:0in 5.4pt 0in 5.4pt;height:69.6pt'>
<p class=MsoNormal>If I meet the qualifications to be an interpreter (which
may require that my proficiency in the language and/or Medical Terminology
be
assessed), you may list my name in the <st1
lace w:st="on"><st1laceNamew:st="on">Medical</st1
laceName> <st1laceTypew:st="on">Center</st1
laceType></st1lace>’sLanguage Bank:</p>
<p class=MsoNormal align=center style='text-align:center'><INPUT
TYPE="CHECKBOX" NAME="Lang Bank Yes">YES<span
style='mso-spacerun:yes'>
</span><INPUT TYPE="CHECKBOX" NAME="lang bank No">NO</p>
<p class=MsoNormal><b style='mso-bidi-font-weight:normal'>If Yes: </b>Are
you
interested in attending <span style='text-transform:uppercase'>Certified
Medical Interpreter</span> classes?<span style='mso-spacerun:yes'>
</span>(Classes are Free and are scheduled during work hours)<span
style='mso-spacerun:yes'>
</span><INPUT TYPE="CHECKBOX" NAME="classes yes">Yes<span
style='mso-spacerun:yes'>
</span><INPUT TYPE="CHECKBOX" NAME="classes no">No</p>
<p class=MsoNormal>Have you taken the NYU Language Assessment?<span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX">Yes<span
style='mso-spacerun:yes'> </span><INPUT TYPE="CHECKBOX">No</p>
</td>
</tr>
</table>
<p class=MsoNormal>Print Your Name: <!--[if gte vml 1]><v:shape
id="_x0000_i1055"
type="#_x0000_t75" style='width:113.25pt;height:18pt'>
<v:imagedata src="online%20survey%20forms_files/image009.wmz" o:title=""
grayscale="t" bilevel="t"/>
</v:shape><![endif]--><![if !vml]><img width=151 height=24
src="online%20survey%20forms_files/image010.gif"
v:shapes="_x0000_i1055"><![endif]>,
<!--[if gte vml 1]><v:shape id="_x0000_i1056" type="#_x0000_t75"
style='width:116.25pt;
height:18pt'>
<v:imagedata src="online%20survey%20forms_files/image011.wmz" o:title=""
grayscale="t" bilevel="t"/>
</v:shape><![endif]--><![if !vml]><img width=155 height=24
src="online%20survey%20forms_files/image012.gif"
v:shapes="_x0000_i1056"><![endif]><span
style='mso-spacerun:yes'> </span>Job Title: <!--[if gte vml 1]><v:shape
id="_x0000_i1057" type="#_x0000_t75" style='width:161.25pt;height:18pt'>
<v:imagedata src="online%20survey%20forms_files/image013.wmz" o:title=""
grayscale="t" bilevel="t"/>
</v:shape><![endif]--><![if !vml]><img width=215 height=24
src="online%20survey%20forms_files/image014.gif"
v:shapes="_x0000_i1057"><![endif]></p>
<p class=MsoNormal style='margin-left:1.0in;text-indent:.5in'>(LAST)<span
style='mso-spacerun:yes'> </span><span
style='mso-tab-count:3'> </span>(FIRST)</p>
<p class=MsoNormal>Department: <!--[if gte vml 1]><v:shape id="_x0000_i1054"
type="#_x0000_t75" style='width:195pt;height:18pt'>
<v:imagedata src="online%20survey%20forms_files/image015.wmz" o:title=""
grayscale="t" bilevel="t"/>
</v:shape><![endif]--><![if !vml]><img width=260 height=24
src="online%20survey%20forms_files/image016.gif"
v:shapes="_x0000_i1054"><![endif]><span
style='mso-spacerun:yes'> </span><span
style='mso-spacerun:yes'> </span>Ext.<!--[if gte vml 1]><v:shape
id="_x0000_i1053" type="#_x0000_t75" style='width:60.75pt;height:18pt'>
<v:imagedata src="online%20survey%20forms_files/image017.wmz" o:title=""
grayscale="t" bilevel="t"/>
</v:shape><![endif]--><![if !vml]><img width=81 height=24
src="online%20survey%20forms_files/image018.gif"
v:shapes="_x0000_i1053"><![endif]><span
style='mso-spacerun:yes'> </span>Date: <!--[if gte vml 1]><v:shape
id="_x0000_i1052" type="#_x0000_t75" style='width:60.75pt;height:18pt'>
<v:imagedata src="online%20survey%20forms_files/image017.wmz" o:title=""
grayscale="t" bilevel="t"/>
</v:shape><![endif]--><![if !vml]><img width=81 height=24
src="online%20survey%20forms_files/image018.gif"
v:shapes="_x0000_i1052"><![endif]></p>
<p class=MsoNormal>Signature: _________________________________<span
style='mso-tab-count:1'> </span><span
style='mso-spacerun:yes'> </span>KRONOS Employee # <!--[if gte vml
1]><v:shape
id="_x0000_i1051" type="#_x0000_t75" style='width:60.75pt;height:18pt'>
<v:imagedata src="online%20survey%20forms_files/image017.wmz" o:title=""
grayscale="t" bilevel="t"/>
</v:shape><![endif]--><![if !vml]><img width=81 height=24
src="online%20survey%20forms_files/image018.gif"
v:shapes="_x0000_i1051"><![endif]><span
style='mso-spacerun:yes'> </span></p>
<p class=MsoNormal><o
> </o></p></form>
</div>
</body>
</html>