Rev 2/06
UNIVERSITY OF ILLINOIS
Survey Research Laboratory
FOR OFFICE USE ONLY:
Date received:
Date interviewed:
Action:
FIELD SUPERVISOR APPLICATION FORM
Chicago Office
Instructions: Save this form to your computer and complete it in Microsoft Word, then e-mail it to
jobs@srl.uic.edu. You also can print this document, fill it out by hand, and fax it to JOBS@SRL at (312)
996-3358.
Full Name:
(FIRST, MIDDLE, LAST)
Local Street Address:
City & State:
ZIP Code:
Home Phone:
Work Phone:
Cell Phone:
E-mail address:
EDUCATION
Please record your education experience below. Begin with your last high school, and list schools or
colleges attended after that.
School or College
City, State
Years Attended
Major
to
to
to
to
1a. Are you currently employed?
Yes
No (SKIP TO Q.2)
1b. How many hours per week are you currently working?
hrs/wk

SKIP TO Q.3 ON NEXT PAGE
2.
Have you ever been employed?
Yes
No  (SKIP TO Q.4a)
Degree/Diploma
3. Please list all relevant employment information, beginning with your current or most recent job.
[1]
Employer
Street address
City, State, ZIP
Job description
Dates of employment
[2]
Employer
Street address
City, State, ZIP
Job description
Dates of employment
[3]
Employer
Street address
City, State, ZIP
Job description
Dates of employment
4a.
Are you currently enrolled in an undergraduate or graduate program?
Yes
No  (SKIP TO Q.5a)
4b.
At what school?
4c.
How many credit hours are you currently taking?
4d.
When do you plan to graduate/get your degree?
hrs/wk
/
MONTH/YEAR
Field supervisor application: Chicago
2
5a.
Do you have any survey research interviewing experience?
Yes
No  (SKIP TO Q.6)
5b.
Have you had experience with . . .
Yes
No
1) Telephone interviewing? ................................................................................
2) Face-to-face interviewing? ..............................................................................
3) Other types of interviewing? (PLEASE SPECIFY TYPES) .........................
5c.
Please describe these survey interviewing experiences if not already listed under
employment. (INCLUDE EMPLOYER AND DATES)
6.
Please list any other experiences (workshops, conferences, work, hobbies, etc.) you may have had
that might be relevant to interviewing or survey research.
7.
Are you usually available for . . .
Yes
8a.
1)
Daytime interviewing?
2)
Evening interviewing?
3)
Weekend interviewing?
No
Please specify any time(s) of the day or week when you are not available.
8b. Please specify any time(s) of the year that you are not available.
Field supervisor application: Chicago
3
9.
What is the maximum number of hours per
week that you could devote to interviewing?
hrs/wk
10a. Do you speak any foreign language(s)
fluently?
Yes
No  (SKIP TO Q.11a)
10b. Which language(s)?
12a. Do you currently have a valid driver’s
license?
Yes
No  (SKIP TO Q.13)
12b. Do you have unrestricted use of an
automobile in good running condition?
Yes
No
13a. Have you ever been convicted of a crime?
Yes
No  (SKIP TO Q.14)
11a. Do you type?
Yes
No  (SKIP TO Q.12a)
13b. If yes, please explain.
11b. How many words per minute?
wpm
14.
List three references, including former employers if possible, who can advise us of your
qualifications. (DO NOT LIST RELATIVES OR PERSONAL FRIENDS.)
[1] Name
Street Address
City, State, ZIP
Phone Number
[2] Name
Street Address
City, State, ZIP
Phone Number
[3] Name
Street Address
City, State, ZIP
Phone Number
Field supervisor application: Chicago
4
15.
Where did you hear about this interviewing position? (PLEASE CHECK ALL THAT APPLY.)
Newspaper ad
Posted ad
Another interviewer (PLEASE SPECIFY INTERVIEWER’S NAME)
Some other source (PLEASE SPECIFY)
16.
Why are you applying for this particular job?
Signature __________________________________________ Date
Please e-mail your completed application to jobs@srl.uic.edu
or fax it to JOBS@SRL at (312) 996-3358
Survey Research Laboratory
412 S. Peoria St., 6th Floor
Chicago, IL 60607
Field supervisor application: Chicago
5