Form Dhs 1277 - Service Questionnaire Page 5
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10Employment
Are you a veteran?
Yes
No
Were you injured during your service?
Yes
No
Are you receiving services from Veteran Affairs Vocational Rehabilitation?
Yes
No
Have you ever had a workers’ compensation claim?
Yes
No
Pending
If yes, what state?
Are you a preferred worker in Oregon?
Yes
No
Disability information
Please list your health conditions/disability(ies)/diagnosis(es) (physical, mental or emotional) in the
order it most affects you.
Condition:
Year of onset
How it affects me:
1.
2.
3.
4.
5.
Please list any medications that you are currently taking for any of the conditions listed above:
Medication:
Purpose:
1.
2.
3.
4.
5.
Counselor notes:
Page 5 of 10
DHS 1277 (10/2016)
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Parent category: Legal