1. Have you ever needed a period of leave from work to care for yourself or a family member (spouse, parent, or child) due to a qualifying family or medical reason? A qualifying medical reason means any of the following: (A) Because of the birth of your child and in order to care for such child; (B) because of the placement of a child with you for adoption or foster care; (C) in order to care for your spouse, child, or parent, due to a serious health condition; (D) because of a serious health condition you had that made you unable to perform the functions of your job; (E) because of an exigency arising out of the fact that your spouse, child, or parent is on covered active duty (or has been notified of an impending call or order to covered active duty) in the Armed Forces.YesNo 2. If yes, were you working in Utah when this need arose?YesNo 3. How long had you worked for your employer when this need arose?0-3 months3-6 months6-9 months9-12 months12+ months 4. How many hours per week were you working for your employer when your family or medical need arose?Less than 20 hours/week20-29 hours/week30-39 hours/week40 or more hours/week 5. What type of family or medical need did you have? 6. Did you take a period of leave (either paid or unpaid) for your family or medical need? If no, proceed to Question 13.YesNo 7. If yes, how much leave did you take? 8. If you did take a period of leave, did you take as much leave as you needed to adequately address your family or medical need?YesNo 9. If not, why? 10. Was any of your leave paid?Yes, all of it was paid leaveA portion of it was paid leaveNo, my leave was all unpaid 11. If any of your leave was paid, what type of paid leave did you take? (check all that apply)Sick or personal leaveVacationPaid family/parental leaveNone of my leave was paidOther 12. If your employer offered paid parental or family leave, how much paid leave did the employer offer? Please indicate the total amount of paid leave your employer offers. For example, if you took only two weeks of paid leave, but your employer offered up to six weeks paid leave, you would write six weeks. 13. If you did not take a period of leave (paid or unpaid), why not? Skip this question if you did take a period of leave.I could not afford to take unpaid leave and my employer did not offer any paid family leaveMy employer did not allow me to take unpaid leaveI was afraid taking a period of leave would negatively impact my professional status, reputation, or future opportunitiesOther 14. How many employees did your employer have at the time you needed and/or took a period of leave? This includes part-time, temporary, seasonal, and full-time employees.1-9 employees10-19 employees20-29 employees30-39 employees40-49 employees50 or more employeesI don't know 15. Any additional comments about your experience with your employer and family/medical leave?Answers to the following questions will be kept confidential and will only be used for potential follow up based on your answers above. Would you be willing to speak with us regarding your experience with your employer and family/medical leave?YesNo Your name (CONFIDENTIAL) Your phone number (CONFIDENTIAL) Your email (CONFIDENTIAL) In what House and Senate district do you live? Not sure? Find out here: http://le.utah.gov/GIS/findDistrict.jsp Prev Next Submit
