DSHS Form 14-050 "Statement of Health, Education, and Employment" - Washington

What Is DSHS Form 14-050?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2018;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Available in Korean;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of DSHS Form 14-050 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 14-050 "Statement of Health, Education, and Employment" - Washington

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Statement of Health,
Education, and Employment
A. Client Information
CLIENT NAME
CLIENT TELEPHONE NUMBER
CLIENT ID NUMBER
BIRTH DATE
SOCIAL SECURITY NUMBER
1. Have you applied for or received the following:
SSI or Social Security Disability benefits, date:
Veteran’s (VA) benefits, date:
2. Are you interested in retraining or vocational rehabilitation services at this time?
Yes
No
3. What is your primary language?
Can you read and write in English?
Yes
No
4. Are you left or right-handed?
Left-handed
Right-handed
B. Health Information
1. Do you have any mental or physical health conditions that currently keep you from working?
Yes
No
If yes, list all health conditions that keep you from working:
2. Have you been treated for these conditions?
Yes
No
If yes, please give us the following information:
CONDITION
CLINIC / HOSPITAL
DATES
TREATMENT / MEDICATION RECEIVED
C. Education and Training
1. What is the highest grade you completed in school (K – 12)?
2. Do you have a high school diploma or High School Equivalency?
Yes
No
3. Did you attend special education classes for reading, writing, or math in high school?
Yes
No
REASON FOR SPECIAL
SCHOOL LOCATION OR
SPECIAL EDUCATION CLASS
GRADE LEVEL
EDUCATION CLASSES
DISTRICT
Have you attended any college or vocational training programs?
Yes
No
If yes, please give us the following information:
COMPLETED
COLLEGE OR VOCATIONAL TRAINING
START / END DATES
CERTIFICATE, LICENSE, OR DEGREE
YES
NO
DSHS 14-050 (REV. 02/2018)
Page 1
Statement of Health,
Education, and Employment
A. Client Information
CLIENT NAME
CLIENT TELEPHONE NUMBER
CLIENT ID NUMBER
BIRTH DATE
SOCIAL SECURITY NUMBER
1. Have you applied for or received the following:
SSI or Social Security Disability benefits, date:
Veteran’s (VA) benefits, date:
2. Are you interested in retraining or vocational rehabilitation services at this time?
Yes
No
3. What is your primary language?
Can you read and write in English?
Yes
No
4. Are you left or right-handed?
Left-handed
Right-handed
B. Health Information
1. Do you have any mental or physical health conditions that currently keep you from working?
Yes
No
If yes, list all health conditions that keep you from working:
2. Have you been treated for these conditions?
Yes
No
If yes, please give us the following information:
CONDITION
CLINIC / HOSPITAL
DATES
TREATMENT / MEDICATION RECEIVED
C. Education and Training
1. What is the highest grade you completed in school (K – 12)?
2. Do you have a high school diploma or High School Equivalency?
Yes
No
3. Did you attend special education classes for reading, writing, or math in high school?
Yes
No
REASON FOR SPECIAL
SCHOOL LOCATION OR
SPECIAL EDUCATION CLASS
GRADE LEVEL
EDUCATION CLASSES
DISTRICT
Have you attended any college or vocational training programs?
Yes
No
If yes, please give us the following information:
COMPLETED
COLLEGE OR VOCATIONAL TRAINING
START / END DATES
CERTIFICATE, LICENSE, OR DEGREE
YES
NO
DSHS 14-050 (REV. 02/2018)
Page 1
D. Work History
1. Are you currently working?
Yes
No
If yes, how much do you earn each month?
2. List your last 10 years of work history beginning with your most recent job (attach additional pages if needed):
JOB TITLE
EMPLOYER
HOURS
MONTH AND YEAR
WHY DID YOU STOP WORKING?
PER WEEK
START:
STOP:
Tell us about what you did at this job:
JOB TITLE
EMPLOYER
HOURS
MONTH AND YEAR
WHY DID YOU STOP WORKING?
PER WEEK
START:
STOP:
Tell us about what you did at this job:
JOB TITLE
EMPLOYER
HOURS
MONTH AND YEAR
WHY DID YOU STOP WORKING?
PER WEEK
START:
STOP:
Tell us about what you did at this job:
JOB TITLE
EMPLOYER
HOURS
MONTH AND YEAR
WHY DID YOU STOP WORKING?
PER WEEK
START:
STOP:
Tell us about what you did at this job:
JOB TITLE
EMPLOYER
HOURS
MONTH AND YEAR
WHY DID YOU STOP WORKING?
PER WEEK
START:
STOP:
Tell us about what you did at this job:
JOB TITLE
EMPLOYER
HOURS
MONTH AND YEAR
WHY DID YOU STOP WORKING?
PER WEEK
START:
STOP:
Tell us about what you did at this job:
JOB TITLE
EMPLOYER
HOURS
MONTH AND YEAR
WHY DID YOU STOP WORKING?
PER WEEK
START:
STOP:
Tell us about what you did at this job:
JOB TITLE
EMPLOYER
HOURS
MONTH AND YEAR
WHY DID YOU STOP WORKING?
PER WEEK
START:
STOP:
Tell us about what you did at this job:
3. List all hobbies and volunteer work you have done in the past 10 years?
IF SOMEONE TRANSLATED OR HELPED YOU FILL OUT THIS FORM, ENTER THEIR NAME AND RELATIONSHIP TO YOU HERE
I declare under penalties of perjury that the information given by me on this Statement of Education,
Employment, and Health is true, correct, and complete to the best of my knowledge. I understand that the
Department of Social and Health Services may require me to provide proof of my statements.
CLIENT’S SIGNATURE
DATE
DSHS 14-050 (REV. 02/2018)
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