Employability Assessment Form printable pdf download

PLEASE READ INSTRUCTIONS BEFORE COMPLETING FORM

COMPLETION INSTRUCTIONS - EMPLOYABILITY ASSESSMENT FORM (PA 1663)

An individual with a physical or mental disability which temporarily or permanently precludes him or her from

any gainful employment may be eligible for General Assistance, GA. This form must be completed to document

the disability.

To implement these requirements, we are asking you to complete this form for an applicant for public assistance.

Who may complete assessment:

The assessment may be performed only by a licensed physician, physician’s

assistant, certified registered nurse practitioner, or psychologist.

Who signs the form:

Only the individual who performed the employability assessment may sign the

form. The signature must be original or the form will be invalidated. Signature

or clinic stamps, labels, and other facsimilies are not acceptable.

General form completion requirements:

The information on the form and attachments must be complete and legible.

The inability of county staff to read your material will result in the client’s

application being delayed and the form being returned to you for clarification.

If possible, the form and any attachments should be typed.

If all questions are not answered fully, the client’s application will be delayed

and the form returned to you for completion.

EMPLOYABILITY SECTION

Permanently Disabled:

Check this block if the client should be considered permanently disabled and,

therefore, unable to work. When making this determination, you must consider

whether the client is unable to engage in any gainful employment by reason

of any medically determinable physical or mental impairments. A medically

determinable physical or mental impairment is an impairment that results from

anatomical, physiological, or psychological abnormalities which can be shown

by medically acceptable clinical and laboratory diagnostic techniques. A

physical or mental impairment must be established by medical evidence

consisting of signs, symptoms, and laboratory findings, not only by the

individual’s statement of symptoms.

Temporarily Disabled:

There are two blocks for use in evaluating a client who is

temporarily disabled - one for a client whose disability is

expected to last 12 months or more, and one for a client whose

disability is expected to last less than 12 months. Check the

appropriate block if the client has an injury or condition that

temporarily prevents the client from working in any gainful

employment. Once the injury or ailment is resolved, the client

can work. The date shown is when the temporary disability is

expected to end. A client whose disability is expected to last 12

or more months may be a candidate for Social Security

Disability or SSI benefits.

Employable:

Check this block if, based on your examination, it is not

appropriate to check either the Permanently or Temporarily

Disabled blocks.

EXAMINATION RESULTS SECTION

This section must be fully completed so that it clearly establishes the basis for your decision that the

client is either temporarily or permanently disabled. Simply providing a diagnosis is not sufficient. You

must provide information about the basis for your diagnosis and assessment. Further, documentation

sufficient to support your decision, for example medical records, X-rays, and lab reports, must be

available for further review if required.

Questions:

Contact your local county assistance office

PA 1663 (SG) 2/10

Employability Assessment Form

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