Form Mc 223 - Applicant'S Supplemental Statement Of Facts For Medi-Cal Page 5
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8PART IV—WORK HISTORY I
County Use Only
17. Describe all of the jobs you have done for at least 30 days during the last 15 years. Start with your
most recent job. (If you had more than two jobs, ask your county worker for additional pages.)
a.
Job Title
Type of Business
Dates Worked (month/year)
Hours Per Week
Rate of Pay
Per hour/wk/mo
From:
To:
DESCRIPTION OF THE JOB (This is what I did and how I did it.)
These are the tools, machines, and equipment I used:
I took this long to learn the job for:
day(s) or
month(s).
I wrote, completed reports, or performed similar duties:
Yes
No
❑
❑
I had supervisory responsibilities:
Yes
No
❑
❑
PHYSICAL ACTIVITY
(Circle One)
I walked this many hours in an average workday:
0
1
2
3
4
5
6
7
8
I stood this many hours in an average workday:
0
1
2
3
4
5
6
7
8
I sat this many hours in an average workday:
0
1
2
3
4
5
6
7
8
I climbed this much in
an average workday:
Never
Occasionally
Frequently
Constantly
❑
❑
❑
❑
I bent over this much in
an average workday:
Never
Occasionally
Frequently
Constantly
❑
❑
❑
❑
Heaviest weight I lifted:
10 lbs
20 lbs
50 lbs
Over 100 lbs
❑
❑
❑
❑
I often lifted/carried up to:
10 lbs
20 lbs
50 lbs
Over 100 lbs
❑
❑
❑
❑
Did you have any of your current medical problem(s) when you performed this job?
Yes
No
❑
❑
If NO, and you have had NO other jobs go to Part V, page 7, for your signature.
If NO, but you have had other jobs, go to 17b, next page.
If YES, please complete the following information.
Name of medical problem(s):
Did your employer make special arrangements (such as extra breaks, special
equipment, change in job duties, etc.) so you could continue to work?
❑
Yes
❑
No
If YES, describe the special arrangements made:
Did you have to stop working because of your medical problem(s)?
❑
Yes
❑
No
If YES, when?
Month
Day
Year
Have you done any other work for more than 30 days during the last 15 years?
❑
Yes
❑
No
If NO, go to Part V, page 7 for your signature. If YES, continue on 17b, next page.
MC 223 (10/09)
Page 5 of 8
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