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Congratulatfons! 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 />Date: <br />Is this a new job? <br /> Yes No Is health insurance available: <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 portfon of the premiums? $ <br />Name and Title of Person Who Completed This Page: <br />DVRSchoolToWork@dshs.wa.gov Page 22 <br /> 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 />Overtfme: Yes; if yes, how often and how much? <br />Work Schedule (in <br /> No <br />clude exact tfmes when possible): <br />Monday Tuesday Wednesday Thursday Friday Saturday Sunday