EMPLOYMENT INFORMATION

· Employer: ___________________________________________________________________

· Job Title: ____________________________________________________________________

· Length of Employment: ________________ Years of Experience in this field: ___________

· What were your job duties?

· Is your job still available? ____________ When did you last work? ______________

· What other jobs or training have you held (please indicate length of time in each)?

· What was the last grade in school you completed?

· What are your plans concerning return to work?