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

This "Form Dshs14-050 La "statement of Health, Education, and Employment" - Washington (Lao)" is a part of the paperwork released by the Washington State Department of Social and Health Services specifically for Washington residents.

The latest fillable version of the document was released on February 1, 2018 and can be downloaded through the link below or found through the department's forms library.

ADVERTISEMENT
ADVERTISEMENT

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

1493 times
Rate (4.6 / 5) 104 votes
VbEc™ g kank Æ W vk z b S u K Afab,ŸkanS j k Sa,ŸElAŸvWkgan
Statement of Health, Education, and Employment
raYlAwWdKwgÏ™ U K M k ansÆ v YeHlJ w
A.
sJ Æ K wgÏU ™ K M
elkotrAS z b KwgÏ U ™ K M
elk
KwgÏ U ™ K M
ID
v z n ek I d
elkpAk z n f z Y S z g ˚ q m
t Æ a nRd ™ K M e w q a Hl J Rd ™ h z b mak Æ w nS i Æ g † B l q g Rpn [ b B :
1.
J e gi n
Hl J eg i n ososeS z W w q g ˚A
v z n t I :
SSI
,
eg i n n z k r q b ek q Æ a
v z n t I :
(VA) ,
t Æ a nS q n VcVnkanb M r i k anƒ j k ƒ q n VHm Æ Hl J kanƒ j k Ewbwas I b VH ™ d I ˚ J n Vnevlan [ b B
Em Æ n
b B E m Æ n
2.
?
faSatµw i d Kwgt Æ a nEm Æ n faSaHY z g
t Æ a nSamadw Æ a n Hl KWnep z n faSaw z g k i d Rd ™ b B
Em Æ n
b B E m Æ n
3.
?
?
t Æ a nep z n ˚ q n Ehgm J s ™ a Y Hl J m J K va
Ehgm J s ™ a Y
Ehgm J K va
4.
?
raYlAwWdk Æ W vk z b S u K Afab
B.
t Æ a nm I b z n HaS u K Afabd ™ a nc i d Vc Hl J h Æ a gkaYs j Æ g k I d k x n t Æ a nVnp z d c u b z n n [ c akkaneh z d vWkb B
Em Æ n
b B E m Æ n
1.
?
T ™ a Em Æ n ,ŸKWnb z n HaS u K Afabt u k @y Æ a gl q g Rps j Æ g k I d k x n t Æ a ncakkaneh z d vWk:
t Æ a ne˚ I Y T J k p i Æ n p q v mak Æ w nb B S µl z b b z n HaeHl q Æ a n[
Em Æ n
b B E m Æ n
2.
?
T ™ a Em Æ n ,ŸkAr u n abwkfvkeh q a raYrAwWd† B l q g Rpn [ :
SAfabkanec z b p Æ v Y
˚l I n i k /ohgfAYaban
v z n t I
kanpi Æ n pq v /yatI Æ R d™ h z b
kanSj k Sa ElA kanƒj k ƒq n
C.
s x n hWnS U g S u d t I Æ t Æ a nRd ™ c q b y U Æ o hghWnEm Æ n s x n Vd
1.
(K – 12)?
t Æ a nRd ™ h z b haYSAk u l d i b oplma
Em Æ n
b B E m Æ n
2.
?
t Æ a nRd ™ e K X a H ™ w ghWnkanS j k Saf i e Sdb B S µl z b kanw Æ a n, kanKWn, Hl J elky U Æ o hghWnhaYSAk u n b B
Em Æ n
b B E m Æ n
3.
?
eHdÏ q n Sµl z b H ™ w ghWn
SATant I Æ K wgohghWn Hl J
H ™ w ghWnkanS j k Saf i e Sd
s x n H ™ w ghWn
kanS j k Saf i e Sd
HmvdohghWn
t Æ a ne˚ I Y eK X a ohghWn˚wneHld Hl J o˚gkanƒj k ƒq n vi s asI b †Æ a g@b B
Em Æ n
b B E m Æ n
?
T ™ a Em Æ n ,ŸkAr u n abwkfvkeh q a raYrAwWd† B l q g Rpn [ :
Sµer z d
ohghWn˚wneHld Hl kanƒj k ƒq n vi s asI b
v z n t I e l [ m † X n /p i d l q g
VbpAkad, VbwAn u Y ad Hl J pr i n Ya
Em Æ n
bB E mÆ n
DSHS 14-050 LA (REV. 02/2018) Laotian
Hn ™ a
1
VbEc™ g kank Æ W vk z b S u K Afab,ŸkanS j k Sa,ŸElAŸvWkgan
Statement of Health, Education, and Employment
raYlAwWdKwgÏ™ U K M k ansÆ v YeHlJ w
A.
sJ Æ K wgÏU ™ K M
elkotrAS z b KwgÏ U ™ K M
elk
KwgÏ U ™ K M
ID
v z n ek I d
elkpAk z n f z Y S z g ˚ q m
t Æ a nRd ™ K M e w q a Hl J Rd ™ h z b mak Æ w nS i Æ g † B l q g Rpn [ b B :
1.
J e gi n
Hl J eg i n ososeS z W w q g ˚A
v z n t I :
SSI
,
eg i n n z k r q b ek q Æ a
v z n t I :
(VA) ,
t Æ a nS q n VcVnkanb M r i k anƒ j k ƒ q n VHm Æ Hl J kanƒ j k Ewbwas I b VH ™ d I ˚ J n Vnevlan [ b B
Em Æ n
b B E m Æ n
2.
?
faSatµw i d Kwgt Æ a nEm Æ n faSaHY z g
t Æ a nSamadw Æ a n Hl KWnep z n faSaw z g k i d Rd ™ b B
Em Æ n
b B E m Æ n
3.
?
?
t Æ a nep z n ˚ q n Ehgm J s ™ a Y Hl J m J K va
Ehgm J s ™ a Y
Ehgm J K va
4.
?
raYlAwWdk Æ W vk z b S u K Afab
B.
t Æ a nm I b z n HaS u K Afabd ™ a nc i d Vc Hl J h Æ a gkaYs j Æ g k I d k x n t Æ a nVnp z d c u b z n n [ c akkaneh z d vWkb B
Em Æ n
b B E m Æ n
1.
?
T ™ a Em Æ n ,ŸKWnb z n HaS u K Afabt u k @y Æ a gl q g Rps j Æ g k I d k x n t Æ a ncakkaneh z d vWk:
t Æ a ne˚ I Y T J k p i Æ n p q v mak Æ w nb B S µl z b b z n HaeHl q Æ a n[
Em Æ n
b B E m Æ n
2.
?
T ™ a Em Æ n ,ŸkAr u n abwkfvkeh q a raYrAwWd† B l q g Rpn [ :
SAfabkanec z b p Æ v Y
˚l I n i k /ohgfAYaban
v z n t I
kanpi Æ n pq v /yatI Æ R d™ h z b
kanSj k Sa ElA kanƒj k ƒq n
C.
s x n hWnS U g S u d t I Æ t Æ a nRd ™ c q b y U Æ o hghWnEm Æ n s x n Vd
1.
(K – 12)?
t Æ a nRd ™ h z b haYSAk u l d i b oplma
Em Æ n
b B E m Æ n
2.
?
t Æ a nRd ™ e K X a H ™ w ghWnkanS j k Saf i e Sdb B S µl z b kanw Æ a n, kanKWn, Hl J elky U Æ o hghWnhaYSAk u n b B
Em Æ n
b B E m Æ n
3.
?
eHdÏ q n Sµl z b H ™ w ghWn
SATant I Æ K wgohghWn Hl J
H ™ w ghWnkanS j k Saf i e Sd
s x n H ™ w ghWn
kanS j k Saf i e Sd
HmvdohghWn
t Æ a ne˚ I Y eK X a ohghWn˚wneHld Hl J o˚gkanƒj k ƒq n vi s asI b †Æ a g@b B
Em Æ n
b B E m Æ n
?
T ™ a Em Æ n ,ŸkAr u n abwkfvkeh q a raYrAwWd† B l q g Rpn [ :
Sµer z d
ohghWn˚wneHld Hl kanƒj k ƒq n vi s asI b
v z n t I e l [ m † X n /p i d l q g
VbpAkad, VbwAn u Y ad Hl J pr i n Ya
Em Æ n
bB E mÆ n
DSHS 14-050 LA (REV. 02/2018) Laotian
Hn ™ a
1
pAv z d vWkgan
D.
t Æ a nkµl z g eh z d vWkVnp z d c u b z n n[ y U Æ b B
Em Æ n
b B E m Æ n T ™ a Em Æ n , t Æ a nHaeg i n Rd ™ e t q Æ a VdVnE† Æ l Aed J w n
1.
?
?
KWnpAv z d vWkganVn
p I Ï Æ a nmaKwgt Æ a nel [ m † X n cakvWkganl Æ a S u d Hm U Æ t I Æ S u d Kwgt Æ a n (˚ z d Hn ™ a ec X W manµT ™ a † ™ w gkan):
2.
10
ed J w n ElA p I
s q Æ v omgeh z d vWk† B w at i d
Hn ™ a t I Æ v Wkgan
naYc ™ a g
ep z n HY z g t Æ a nc j Æ g y u d eh z d vWk
?
el [ m † X n
:
y u d
:
c q Æ g bwkfvkeh q a k Æ W vk z b S i Æ g t I Æ t Æ a nRd ™ e h z d y U Æ V nvWkn [ :
ed J w n ElA p I
s q Æ v omgeh z d vWk† B w at i d
Hn ™ a t I Æ v Wkgan
naYc ™ a g
ep z n HY z g t Æ a nc j Æ g y u d eh z d vWk
?
el [ m † X n
:
y u d
:
c q Æ g bwkfvkeh q a k Æ W vk z b Si Æ g tI Æ t Æ a nRd™ e hz d yU Æ V nvWkn[ :
ed J w n ElA p I
s q Æ v omgeh z d vWk† B w at i d
Hn ™ a t I Æ v Wkgan
naYc ™ a g
ep z n HY z g t Æ a nc j Æ g y u d eh z d vWk
?
el [ m † X n
:
y u d
:
c q Æ g bwkfvkeh q a k Æ W vk z b S i Æ g t I Æ t Æ a nRd ™ e h z d y U Æ V nvWkn [ :
ed J w n ElA p I
s q Æ v omgeh z d vWk† B w at i d
Hn ™ a t I Æ v Wkgan
naYc ™ a g
ep z n HY z g t Æ a nc j Æ g y u d eh z d vWk
?
el [ m † X n
:
y u d
:
c q Æ g bwkfvkeh q a k Æ W vk z b S i Æ g t I Æ t Æ a nRd ™ e h z d y U Æ V nvWkn [ :
ed J w n ElA p I
s q Æ v omgeh z d vWk† B w at i d
Hn ™ a t I Æ v Wkgan
naYc ™ a g
ep z n HY z g t Æ a nc j Æ g y u d eh z d vWk
?
el [ m † X n
:
y u d
:
c q Æ g bwkfvkeh q a k Æ W vk z b S i Æ g t I Æ t Æ a nRd ™ e h z d y U Æ V nvWkn [ :
ed J w n ElA p I
s q Æ v omgeh z d vWk† B w at i d
Hn ™ a t I Æ v Wkgan
naYc ™ a g
ep z n HY z g t Æ a nc j Æ g y u d eh z d vWk
?
el [ m † X n
:
y u d
:
c q Æ g bwkfvkeh q a k Æ W vk z b S i Æ g t I Æ t Æ a nRd ™ e h z d y U Æ V nvWkn [ :
ed J w n ElA p I
s q Æ v omgeh z d vWk† B w at i d
Hn ™ a t I Æ v Wkgan
naYc ™ a g
ep z n HY z g t Æ a nc j Æ g y u d eh z d vWk
?
el [ m † X n
:
y u d
:
c q Æ g bwkfvkeh q a k Æ W vk z b S i Æ g t I Æ t Æ a nRd ™ e h z d y U Æ V nvWkn [ :
ed J w n ElA p I
naYc ™ a g
s q Æ v omgeh z d vWk† B w at i d
Hn ™ a t I Æ v Wkgan
ep z n HY z g t Æ a nc j Æ g y u d eh z d vWk
?
el [ m † X n
:
y u d
:
c q Æ g bwkfvkeh q a k Æ W vk z b S i Æ g t I Æ t Æ a nRd ™ e h z d y U Æ V nvWkn [ :
KWnl q g RpS i Æ g t I Æ m z k Hl [ n ElA vWkwaSaSAm z k † Æ a g@t I Æ t Æ a nRd ™ e h z d maVn
p I Ï Æ a nma
3.
10
?
T ™ a Hakv Æ a ˚ q n Vd˚ q n n j Æ g Rd ™ E pfaSa Hl J s Æ v YeHl J w t Æ a nKWnpAkwbFwmVbn [ , KWnsJ Æ ElA ˚vamS z m f z n KwgeK q a ec X a † B t Æ a nVS Æ b Æ w nn [ .
K ™ a fAec X a K M E c ™ g v Æ a faYR† ™ k anp z b RHml q g otdKwgkanev X a et z d v Æ a raYlAwWdt I Æ T J k ew q a VH ™ o dYK ™ a fAec X a y U Æ V nVbEc ™ g kanVbn [ k Æ W vk z b kanS j k Sa,
vWkgan, ElA S u K Afabep z n ˚vamc i g , TJ k †™ w g ElA ˚q b T™ v nwI g †am˚µhz b hU ™ t I Æ d I t I Æ S u d KwgK™ a fAecX a . K ™ a fAec X a eK X a Vcv Æ a k q m S z g ˚ q m S q g e˚aA ElA
SatarAnAS u k wadcAb q Æ g VH ™ K ™ a fAec X a t I Æ cAS q Æ g Hl z k TanKwg˚µEc ™ g kanKwgK ™ a fAec X a maVH ™ .
v z n t I
laYes z n KwgÏ U ™ h z b kans Æ v YeHl J w
Hn ™ a
DSHS 14-050 LA (REV. 02/2018) Laotian
2
Page of 2