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WORK ACTIVITY REPORT - EMPLOYEE
ND DEPARTMENT OF HUMAN SERVICES
MEDICAL ASSISTANCE
SFN 1078 (Rev. 5/2005)
Name of Claimant or Beneficiary
.
Name of Wage Earner (If other than Claimant or Beneficiary)
Please use this form to describe your work activity since
ANSWER THE QUESTIONS ON THIS FORM AND RETURN IT AND ANY OTHER INFORMATION ABOUT YOUR CLAIM TO
THE STATE REVIEW TEAM AT THE ADDRESS LISTED IN THE UPPER RIGHT HAND CORNER OF THIS FORM.
Date (to be entered by SRT)
1.
2.
2.
Note: This form has 8 pages.
Send to: State Review Team
ND Department of Human Services
600 E Boulevard Ave, Dept. 325
Bismarck, ND 58505
Fax: (701) 328-1544
IDENTIFICATION
Claimant or Beneficiary is Receiving:
PART I - TO BE COMPLETED BY THE DEPARTMENT OF HUMAN SERVICES
We need to know this information to determine periods of actual work activity as opposed to periods of just employment (i.e. sick
leave, vacation pay, etc.)
PART II - TO BE COMPLETED BY PERSONS APPLYING FOR OR RECEIVING BENEFITS
You should answer each of the questions below as best and with as many details as you can. This information will help up decide if you
should get or keep getting benefits. For any question below, if you need more space, use item 9, on pages 5 and 6. Remember to write the
number of the question that you are answering in item 9.
1.
HAVE YOU WORKED SINCE THE DATE SHOWN IN ITEM 1OF PART 1, ABOVE?
YES
NO
If you did work, go to item 3 and answer the rest of the questions and sign and date the form.
If you did not work, but earnings were reported for you as shown in item 2 of Part I above, go to item 2 below.
REPORT WORK OR EARNINGS
If you did not work, but earnings were reported for you as shown in item 2 of Part 1, explain what the pay was for.
For example, sometimes pay is sick pay, vacation pay or holiday pay that you earned, or for work that you did before becoming unable
to work because of your condition.
If you can't explain the earnings reported for you or you don't remember what the total earnings are for, ask your employer(s).
Explanation of Earnings
If you need more space, use Item 9. Then go to Items 8 and 10.
Blind Not Blind
Social Security Disability Insurance (SSDI) Benefits Both SSDI and SSI Disability Benefits
Supplemental Security Income (SSI) Disability Benefits Neither SSDI or SSI Disability Benefits
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