Employability Re-Assessment Form Pa 1664 - Department Of Public Welfare
Download a blank fillable Employability Re-Assessment Form Pa 1664 - Department Of Public Welfare in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Employability Re-Assessment Form Pa 1664 - Department Of Public Welfare with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3PLEASE READ INSTRUCTIONS BEFORE COMPLETING FORM
COMPLETION INSTRUCTIONS - EMPLOYABILITY RE-ASSESSMENT FORM (PA 1664)
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/recipient for public assistance
whose initial eligibility for GA or whose exemption from work requirements was based on a temporary disability. The client
has indicated that he/she continues to be temporarily disabled. Your assessment is necessary to help the Department of
Public Welfare, DPW, make the decision to continue or reauthorize GA.
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
The information on the form and attachments must be complete and legible.
requirements:
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 begin date shown is when the disability began. The end date shown is
when the temporary disability is now 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. In the space provided, indicate why
the temporary disability did not end when originally expected. Also, check
the appropriate block regarding whether the client followed a prescribed
treatment plan.
If you are not the physician or psychologist who made the original
diagnosis, the client should provide you with that person’s name and
telephone number. You are asked to contact him/her if you deem it
appropriate for a consultation to obtain information concerning the original
diagnosis.
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 1664 (SG) 2/10
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Lea-pst - Safety Telecommunicator Training Paperwork Checklist Form - New Mexico Department Of Public Safety Training Center
Legal
Continuation Of Certification Annual Firearms Training Report Form - New Mexico Department Of Public Safety Training Center
Legal
Application For Approval Of Sanitary Facilities For A Realty Subdivision Form - Monroe County Department Of Public Health
Legal
Ears/hearing Accomodation Field Exam Form - New Mexico Department Of Public Safety Training Center
Legal
Related Categories
Parent category: Legal