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Phase 3 Starts: Employment <br />This phase serves as an exciting step to complete and capture all employment stabilization information <br />like employment verification information, completion of the first day of work, and much more! <br />Congratulations! You are Employed! <br />Now what? Please work with your job coach to complete the form below. <br />Employee's Name: <br />Employer's Name: <br />Employee's Job Title: <br />Employer's Address: <br />Is this a new job? No Yes Date Employee Started Work: <br />Average Number of Hours Worked Per Week: <br />Rate of Pay or Salary: $ <br />Pay Frequency: <br />Daily Weekly Every Two Weeks <br />Hourly ❑ Monthly I Annually <br />Two Times a Month -1 Monthly <br />Tips: No L Yes; if yes, how often and how much? <br />Commissions: 7, No L Yes; if yes, how often and how much? <br />Bonuses: I No Yes; if yes, how often and how much? <br />Overtime: n No Yes; if yes, how often and how much? <br />Work Schedule (include exact times when possible): <br />Monday Tuesday Wednesday Thursday Friday <br />Is health insurance available: No Yes <br />1. If yes, did the employee enroll in the health plan?: No <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: <br />Date: <br />Yes <br />Saturday Sunday <br />DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 13 <br />