Form Mc 223 - Applicant'S Supplemental Statement Of Facts For Medi-Cal (Hmong) Page 6
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8SEEM IV—KEV UA HAUJ LWM YAV TAS LOS II
County Use Only
17. b.
Lub Npe Ntawm Txoj Hauj Lwm
Hom Lag Luag Dab Tsi
Cov Hnub Tim Ua Hauj Lwm (hli/xyoo)
Ua Pes Tsawg Teev Ntawm Ib As Thiv Twg Tau nyiaj (rate of pay) Txog rau thaum:
Thaum:
Tauj ib teev/as thiv/hli:
QHIA SEB TXOJ HAUJ LWM UA LI CAS (Qhov no yog yam kuv ua thiab kuv ua li no.)
Cov no yog cov twj, cov tshuab, thiab cov khoom uas kuv siv:
Kuv siv sij hawm ntev npaum li no los kawm txoj hauj lwm:
hnub los yog
hli.
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Kuv sau, teb cov ntawv qhia (reports), los yog ua tej yam hauj lwm muaj ntsis zoo li ntawd:
Yog
Tsis yog
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Kuv muaj cov dej num los saib xyuas hauj lwm:
Muaj
Tsis
COV KEV SIV LUB CEV UA
(Kos Voj Voog Rau Ib Qho)
Kuv taug kev npaum no teev hauv ib hnub ua hauj lwm hauj sim (average) twg:
0
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Kuv sawv ntsug npaum no teev hauv ib hnub ua hauj lwm hauj sim (average) twg:
0
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8
Kuv zaum npaum no teev hauv ib hnub ua hauj lwm hauj sim (average) twg:
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Kuv nce npaum no hauv ib hnub ua hauj
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lwm hauj sim (average) twg:
Yeej tsis ua li
Qee zaus ua
Nquag ua
Ua tas li
Kuv khoov npaum no teev hauv ib hnub ua hauj
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lwm hauj sim (average) twg:
Yeej tsis ua li
Qee zaus
Nquag ua
Ua tas li
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Qhov nyhav tshaj uas kuv nqa tau:
10 lbs
20 lbs
50 lbs
tshaj 100 lbs
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Feem ntau kuv tsaws/nqa txog:
10 lbs
20 lbs
50 lbs
tshaj 100 lbs
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Koj puas muaj koj cov mob tam sim no thaum uas koj ua txoj hauj lwm no?
Muaj
Tsis muaj
Yog tias TSIS MUAJ, thiab koj TSIS muaj lwm txoj hauj lwm mus rau Seem V, nplooj 7, rau koj kos npe.
Yog TSIS MUAJ, tiam sis koj muaj lwm cov hauj lwm, nug kom koj tus neeg tuav ntaub ntawv hauv lub nras muab ib co
ntawv ntxiv rau koj.
Yog hais tias MUAJ, thov teb cov lus nram qab no.
Lub npe ntawm tus (cov) mob:
Koj tus tswv hauj lwm puas ua ib co kev npaj tshwj xeeb (xws li so tshaj, lub twj tshwj xeeb, hloov cov dej num hauv
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txoj hauj lwm, zoo li no txuas mus) kom koj thiaj ua tau hauj lwm mus txuas ntxiv?
Ua
Tsis ua
Yog Ua, qhia seb tau ua cov kev npaj tshwj xeeb dab tsi:
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Puas yog koj tsum tsis ua hauj lwm vim koj muaj mob?
Yog
Tsis yog
Yog tias YOG, thaum twg?
Hli
Hnub
Xyoo
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Koj puas tau ua lwm yam hauj lwm mus ntev tshaj 30 hnub hauv 15 xyoos tas los?
Tau
Tsis tau
Yog tias TSIS TAU, mus rau Seem V, nplooj 7 rau qhov chaw kos npe. Yog tias TAU, nug kom koj tus neeg tuav ntaub ntawv
hauv lub nras muab ib co ntawv rau koj teb.
MC 223 (Hmong) (10/09)
Nplooj 6 ntawm 8
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