Form Dhs 1277 - Service Questionnaire Page 4
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10Employment
Employer 3:
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 4:
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 5:
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):
Counselor notes:
Page 4 of 10
DHS 1277 (10/2016)
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Parent category: Legal