Form Dhs 1277 - Service Questionnaire Page 3

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Medical insurance information
Check all that apply:
Medicaid
Private insurance (other)
Workers’ compensation
Medicare
Private insurance (own employer)
None
OHP (Oregon Health Plan)
Public insurance (other)
Counselor notes:
Employment
Are you currently employed?
Yes
No
Hours per week:
Salary:
Hourly wage:
Are you a migrant or seasonal farm worker?
Yes
No
Please list the most recent job you had first.
Employer 1:
Job title:
Job duties:
Did you have any difficulties with these duties because of your disability?
Yes
No
If yes, how?
Start date:
End date:
Last salary/pay rate:
Full time
Part time
Reason for leaving:
Terminated
Laid off
Quit
Relocated/moved
Other
(Please explain):
Employer 2:
Job title:
Job duties:
Did you have any difficulties with these duties because of your disability?
Yes
No
If yes, how?
Start date:
End date:
Last salary/pay rate:
Full time
Part time
Reason for leaving:
Terminated
Laid off
Quit
Relocated/moved
Other
(Please explain):
Page 3 of 10
DHS 1277 (10/2016)

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