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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 />ls this a new job? No Yes Date Employee Started Work: <br />Average Number of Hours Worked Per Week: <br />Rate of Pay or Salary: S HourlY <br />Pay Frequency: <br />Daily Weekly EveryTwo 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 />Monthly Annually <br />Bonuses:No <br />Overtime:No <br />Yes; if yes, how often and how much? <br />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 />ls health insurance available:No Yes <br />1.lf yes, did the employee enroll in the health plan?: <br />a. lf yes, when does the coverage begin? <br />b.lf yes, what is the employee's portion of the premiums? 5 <br />Name and Title of Person Who Completed This Page: <br />Date: <br />No Yes <br />DlvlsloN oF vocATloNAL REHABILITATION ISCHOOL-TO-WORK IPAGE 13