Jeanne Holverstott, MS
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Current Job and Company
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Regarding your current job, please answer the following: 1. Dates worked, 2. Top three problems you have had, and 3. Description of any disciplinary action taken against you.
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Previous Job and Company
Regarding this previous job, please answer the following: 1. Dates worked, 2. Top three problems you had, 3. Description of any disciplinary action taken against you, and, 4. Why you left this job.
Sensory Challenges at Work
Answer these questions prioritizing your current job but also incorporating information from previous jobs as you believe applicable.
Do you find that your work environment has auditory stimuli that are too loud, distracting, bothersome, and/or painful? If so, please detail those below.
Do you find yourself finding ways to decrease auditory distractions at work? If so, how often and what circumstances lead you to apply them?
How would you describe the lighting at your job? Does it bother, distract, or hurt you in any way? If so, please describe.
Do you wear a work uniform? If so, does this uniform cause any sensory discomfort?
Socializing at Work
Answer these questions prioritizing your current job but also incorporating information from previous jobs as you believe applicable.
How would you describe yourself socially at work?
Are you expected to socialize in ways at work or for work that you are uncomfortable with, frustrated by, or confused by? If so, please detail below.
Are there social situations at work that do not involve you that you are confused by?
Do you have friends at work? If so, how did you become friends? Do you spend time together outside of work?
Have you ever been reprimanded at work for socially related problems? If so, please explain.
Have you ever experienced work-place bullying? If so, please explain.
General
Have experiences in the work environment led you to believe you are autistic? If so, please explain 1 or 2 of those situations below.
Do you have accommodations at work? If so, please list those below.
Jeanne Holverstott, MS
About
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