Employability Re-Assessment Form Pa 1664 - Department Of Public Welfare Page 2
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1
2
3RESET FIELDS
CASE IDENTIFICATION
CAO NAME AND ADDRESS
CO
RECORD NUMBER
CAT
CSLD
DIST
RECORD NAME
DATE
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE
EMPLOYABILITY RE-ASSESSMENT FORM
WORKER:
SECTION I (Must be completed by applicant/recipient for public assistance)
PLEASE PRINT OR WRITE CLEARLY. BE SURE TO SIGN YOUR NAME AND DATE THIS FORM IN THE
APPROPRIATE SPACE BELOW.
NAME:
BIRTHDATE:
SOCIAL SECURITY NO.:
ADDRESS:
TELEPHONE NUMBER:
CITY:
STATE:
ZIP CODE:
YOU HAVE PREVIOUSLY PROVIDED AN EMPLOYABILITY ASSESSMENT FORM INDICATING
THAT YOU HAD A TEMPORARY DISABILITY. BRIEFLY EXPLAIN WHY YOU ARE STILL UNABLE
TO WORK EVEN THOUGH YOUR MEDICAL PROVIDER INDICATED ON THE ORIGINAL
EMPLOYABILITY ASSESSMENT FORM THAT YOUR TEMPORARY DISABILITY WAS EXPECTED TO
END BY
.
WAS A TREATMENT PLAN PRESCRIBED FOR YOU BY YOUR MEDICAL PROVIDER?
YES
NO
IF YES, DID YOU FOLLOW IT?
YES
NO
IF NO. PLEASE EXPLAIN WHY NOT.
I HEREBY AUTHORIZE ALL MEDICAL PROVIDERS TO RELEASE ANY MEDICAL INFORMATION
THAT IS RELATED TO MY EMPLOYABILITY TO THE PENNSYLVANIA DEPARTMENT OF PUBLIC
WELFARE. THE INFORMATION OBTAINED WILL BE USED ONLY FOR PURPOSES RELATED TO
AN ASSESSMENT OF MY ABILITY TO WORK AND MY ELIGIBILITY FOR PUBLIC ASSISTANCE.
X X
(SIGNATURE) PUBLIC ASSISTANCE APPLICANT/RECIPIENT
PRINT NAME
DATE
AFTER YOU HAVE COMPLETED THIS SECTION, ARRANGE FOR AN APPOINTMENT WITH A
LICENSED PHYSICIAN (MEDICAL DOCTOR OR DOCTOR OF OSTEOPATHY), PHYSICIAN’S
ASSISTANT, CERTIFIED REGISTERED NURSE PRACTITIONER, OR PSYCHOLOGIST. GENERAL
ASSISTANCE BENEFITS CANNOT BE AUTHORIZED FOR YOU UNTIL THE FULLY-COMPLETED
FORM IS RETURNED TO THE COUNTY ASSISTANCE OFFICE WORKER.
RETURN TO:
PA 1664 (SG) 2/10
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