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Congratulations! You are Employed! <br />NOW what? Please work with your job coach to complete the form below. <br />Employee's Name: Employer's Name: <br />Employee's Job Title: Employer's Address: <br />Is this a new job? ❑ No ❑ Yes <br />Date Employee Started Work: <br />Average Number of Hours Worked Per Week: <br />Rate of Pay or Salary: $ <br />Hourly ❑ Monthly ❑ Annually ❑ <br />Pay Frequency: <br />Daily ❑ Weekly ❑ Every Two Weeks ❑ Two Times a Month ❑ Monthly ❑ <br />Tips: ❑ No ❑ Yes; if yes, how often and how much? <br />Commissions: ❑ No ❑ Yes; if yes, how often and how much? <br />Bonuses: ❑ No ❑ Yes; if yes, how often and how much? <br />Overtime: ❑ No ❑ Yes; if yes, how often and how much? <br />Work Schedule (include exact times when possible): <br />Monday Tuesday Wednesday Thursday Friday Saturday Sunday <br />Is health insurance available: ❑ No ❑ Yes <br />1. If yes, did the employee enroll in the health plan? ❑ No ❑ Yes <br />a. If yes, when does the coverage begin? <br />b. If yes, what is the employee's portion of the premiums? $ <br />Name and Title of Person Who Completed This Page: Date: <br />DVRSchoolToWork@dshs.wa.gov Page 22 <br />