(Check off when finished.)

□ Information About You

□ Factsheet 1– Impairments

□ Factsheet 2– Doctors

□ Factsheet 3–Hospitals

□ Factsheet 4– Medication & Therapy

□ Factsheet 5– Daily Activities

□ Factsheet 6 – Work History

List of Factsheets

?

You

Friend or Relative Who Will Know Where You Are

Other Information

Notes

Name of Applicant: __________________________ Helping Hand Page ? - 2

Factsheet

1

Please list every medical condition that limits your ability to do any task at a place of work or at home.

Name of Applicant: __________________________ Helping Hand Page 1 - 2

Factsheet

2

Name the doctors you saw, and clinics you visited, and the dates you were there, for any condition that causes your disability or makes it worse– give up to date addresses and phone numbers too.

Name of Applicant: __________________________ Helping Hand Page 2 - 2

Factsheet

3

Give the names and addresses of all hospitals where you have been for any condition which causes your disability or makes it worse, and give the dates you were there.

Helping Hand

Name of Applicant: __________________________ Helping Hand Page 3 - 2

Factsheet

4

List all medications and therapy that doctors have told you to take (prescription and non-prescription) beginning with what you are taking now, and going back.

Name of medication Date First Taken No. of Times Reason for Doctor Who Ordered & Size of Dose Taken Daily Medication You to Take

Type of Therapy Dates Began/Ended How Often? Purpose Doctor

Notes

Name of Applicant: __________________________ Helping Hand Page 4 - 2

Factsheet

5

A. Are You Working

B. Activities of Daily Living

Name of Applicant: __________________________ Helping Hand Page 5 - 2

Work History

Your Name _______________________________________________ Date ______________Social Security No. __________________________ Helper ___________________________

A. General Information1. YOUR MOST RECENT JOB

Are you presently employed? ( ) Yes ( ) No

Date you last worked? _________________

For whom were you working at the time? _____________________________________________________

2. EDUCATION.

What was the highest grade completed in school? ________________________

Year you completed that grade: ________________________

Have you had psychological testing? ( ) Yes ( ) No

If so, please give the date(s), describe the test(s), and identify who performed the testing. ___________________ ________________________________________________________________________

B. Past JobsBeginning with most recent job, list every job of the past 15 years.

1. YOUR MOST RECENT JOB (JOB 1)

EMPLOYER: ____________________________________________________________________________ JOB TITLE: _____________________________________________________________________________ Address: _______________________________________________________________________________ Telephone No.: __________________________________________________________________________ Date Began Job: ___________________________ Date Ended Job: _________________________________

a. What were the most demanding physical and mental tasks of this job: ____________________________________________________________________________________________________________________________________________________________

b. In your present condition, are you able to perform the physical and mental requirements of this job 8 hours a day, 5 days a week, year round? ( ) Yes ( ) No. If not, please explain what impairments would prevent you from performing this job.____________________________________________________________________________________________________________________________________________________________

Social Security regulations ask information on the major jobs you have held in the past 15 years. A "major" job is one you held long enough to learn it and perform it competently. Begin with most recent job, and work back.

Factsheet

6Helping Hand

2. YOUR PREVIOUS JOB (JOB 2) EMPLOYER: _______________________________________________________________________ JOB TITLE: ________________________________________________________________________ Address: __________________________________________________________________________ Telephone No.: _____________________________________________________________________ Date Began Job: ______________________ Date Ended Job: _________________________________

a. What were the most demanding physical and mental tasks of this job: __________________________________________________________________________________________________________________________________________________________________

b. In your present condition, are you able to perform the physical and mental requirements of this job 8 hours a day, 5 days a week, year round? ( ) Yes ( ) No. If not, please explain what impairments would prevent you from performing this job.__________________________________________________________________________________________________________________________________________________________________

3. YOUR PREVIOUS JOB (JOB 3) EMPLOYER: _______________________________________________________________________ JOB TITLE: ________________________________________________________________________ Address: __________________________________________________________________________ Telephone No.: _____________________________________________________________________ Date Began Job: ______________________ Date Ended Job: _________________________________

a. What were the most demanding physical and mental tasks of this job: __________________________________________________________________________________________________________________________________________________________________

b. In your present condition, are you able to perform the physical and mental requirements of this job 8 hours a day, 5 days a week, year round? ( ) Yes ( ) No. If not, please explain what impairments would prevent you from performing this job.__________________________________________________________________________________________________________________________________________________________________

4. YOUR PREVIOUS JOB (JOB 4) EMPLOYER: _______________________________________________________________________ JOB TITLE: ________________________________________________________________________ Address: __________________________________________________________________________ Telephone No.: _____________________________________________________________________ Date Began Job: ______________________ Date Ended Job: _________________________________

a. What were the most demanding physical and mental tasks of this job: ______________________________________________________________________________________________________________________________________________________

b. In your present condition, are you able to perform the physical and mental requirements of this job 8 hours a day, 5 days a week, year round? ( ) Yes ( ) No. If not, please explain what impairments would prevent you from performing this job.__________________________________________________________________________________________________________________________________________________________________

APPLICANT STATEMENT

The information listed above is complete and correct to the best of my knowledge.

Date _____________________ Signature of Applicant ____________________________________

Name of Applicant: __________________________ Helping Hand Page 6 - 2

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