Work Activity Worksheet
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For any jobs you held, especially your current or last job, have you worked under any special conditions listed below? If yes, note the special condition, employer name and dates. Also describe the condition.
- Had extra help, extra supervision or a job coach
- ___________________________________________________________________
- ___________________________________________________________________
- ___________________________________________________________________
- Worked irregular or fewer hours than other workers
- ___________________________________________________________________
- ___________________________________________________________________
- ___________________________________________________________________
- Given special equipment because of my condition
- ___________________________________________________________________
- ___________________________________________________________________
- ___________________________________________________________________
- Took more rest periods than other workers
- ___________________________________________________________________
- ___________________________________________________________________
- ___________________________________________________________________
- Given special transportation to and from work
- ___________________________________________________________________
- ___________________________________________________________________
- ___________________________________________________________________
- Had fewer or easier duties than other workers
- ___________________________________________________________________
- ___________________________________________________________________
- ___________________________________________________________________
- Allowed to produce less work than other workers
- ___________________________________________________________________
- ___________________________________________________________________
- ___________________________________________________________________
- Hired through special training or therapy program
- ___________________________________________________________________
- ___________________________________________________________________
- ___________________________________________________________________
- Given work that was suited to my condition
- ___________________________________________________________________
- ___________________________________________________________________
- ___________________________________________________________________
- Given special help getting ready for work
- ___________________________________________________________________
- ___________________________________________________________________
- ___________________________________________________________________
- Other
- ___________________________________________________________________
- ___________________________________________________________________
- ___________________________________________________________________
If your work activity changed, what was the reason? (note: employer name, and date(s)
- Stopped working
- ___________________________________________________________________
- ___________________________________________________________________
- My physical and/or mental condition(s)
- ___________________________________________________________________
- ___________________________________________________________________
- Special conditions that allowed me to work were removed
- ___________________________________________________________________
- ___________________________________________________________________
- Changed to a lighter or easier type of work
- ___________________________________________________________________
- ___________________________________________________________________
- Other
- ___________________________________________________________________
- ___________________________________________________________________
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