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Fhase S Starts; HrnBloYment <br />This phase serves as an exciting step to comptete and capture-all-ernployment stabllizal <br />lrr." anlplov*"nt ,"riti."i""'uir.rri"a"n, .I.pi"iion "i,tr" flrst day of work, and rnuch more! <br />eong rata"ilatBcnsE You are Ermpfloyedl <br />Now what? Please work with your job coach to complete the form below' <br />Employee's Name: <br />tmployer's Namc: <br />Employee's Job Title: <br />Employer's Address: <br />ls this a new job? No i I ves i Date Employee started work: <br />Average Number of Hours Worked Per Week: <br />Rate of Pay or Salary: 5 Hourly ; Monthly : <br />Pay Frequency: <br />i , tr.,o^, Trarn \A/ tes a Month ,Dailyi i Weeklyi , EveryTwoWeeksr ' TwoTin <br />Tips: i ] *" i I Yes; if yes, how often and how much? <br />Commissions: I i frf o I Yes;if yes, how often and how much? <br />Bonuses: ; , No ' ' Yes;if yes, how often and how much? <br />Overtime: I ; No i Yes; if yes, how often and how much? <br />Work Schedule (include exact times when possible): <br />Monday Tuesday Wednesday Thursday Friday <br />Annually: <br />t <br />Monthly I <br />Saturday SundaY <br />ls health insurance available: i lto , , Yes <br />'1. lf yes, did the employee enroll in the health plan?: i i ruo ; ' <br />Yes <br />a. lf yes, when does the coverage begin? <br />b, lf yes, what is the employee's portion of the premiums? $ <br />NameandTitleofPersonWhoCompletedThisPage: <br />Date: <br />DlVl5loNoFVoCATloNALREHABlLiTAiioNlisCHCoL-To-\^/oRKIPAGE13