The Pers 543 form, issued by the Texas Department of Criminal Justice, serves a fundamental role in the work history documentation for workplace accommodation requests. This form comprehensively covers an individual's employment background, willingness to work beyond conventional hours, including weekends, and travel availability. It extends into more specific areas such as driver's license details if the position requires, educational achievements including college or university transcripts, and any professional licenses or certifications pertinent to the job sought. Additionally, it delves into special training, skills, or qualifications that the applicant might possess, laying a foundation for employers to assess the suitability of accommodations. A notable feature of the Pers 543 form is its meticulous breakdown of work history, requiring details like position titles, names of immediate supervisors, types of employment (full-time, part-time, temporary), and reasons for leaving past positions. This attention to detail ensures that the screening process for job reassignments due to accommodation needs is based on precise and comprehensive work history data.
| Question | Answer |
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| Form Name | Form Pers 543 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | Undergraduate, calculators, CERTIFICATION, issuing |
Texas Department of Criminal Justice
Work History for Workplace Accommodation
NAME
(Last)(First)(Middle)
Are you willing to work hours other |
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than 8 a.m. - 5 p.m.? |
Yes |
No |
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Are you willing to work on Saturdays? |
Yes |
No |
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Are you willing to travel? |
Yes |
No |
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Driver License (if required for this position) |
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(State) |
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(Number) |
Social Security No. |
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Are you willing to work on Sundays? |
Yes |
No |
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If yes, what percent of time? |
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Class A |
Class B |
Class C |
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Class M |
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Class A Commercial |
Class B Commercial |
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Class C Commercial |
Class M Commercial |
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If applicable, provide transcript for college or university education claimed.
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Type |
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Dates Attended |
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Sem/Clock |
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Major/Minor |
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of |
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Name and Location |
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of Diploma |
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of School |
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Completed |
or Degree |
of Study |
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Undergraduate |
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Colleges |
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or Universities |
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Graduate |
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Schools |
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Technical, |
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Vocational, |
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or Business |
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Schools |
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Date Received |
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Time Received |
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Received by |
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If a license, certificate, or other authorization is required or related to the position for which you are applying, complete the following:
LICENSE/CERTIFICATION
(P.E., R.N., Attorney, C.P.A., etc.)
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Date issued |
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Date expires |
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Issued by/Location of issuing authority (State or other authority) (City & State)
License No.
Special Training/Skills/Qualifications: List all job related training or skills you possess and machines or office equipment you can use, such as calculators, printing or graphics equipment, computer equipment, types of software and hardware. (Attach additional page, if necessary.)
Approximately how many words per minute do you type?
PERS 543 (02/11) |
Page 1 of 3 |
When completing the Work History, be specific about your duties and responsibilities in the Summary of Experience Section. This is the only document that shall be used to screen for minimum qualifications if a
job reassignment is required.
Position Title: |
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Immediate Supervisor Name: |
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Employer: |
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Mailing Address: |
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Title: |
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City & State/ZIP: |
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Temp/Project |
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Employer’s Telephone No.: AC ( |
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Supervisor’s Telephone No.: |
Give average # |
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Starting Date |
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Leaving Date |
Current/ |
Technical |
AC ( |
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of hours worked per |
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Yr. |
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Final Salary |
If supervisory, number of employees you |
week if |
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Supervisory/Managerial |
supervised: |
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Summary of experience: |
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Specific reason for leaving: |
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Position Title: |
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Immediate Supervisor Name: |
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Employer: |
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Mailing Address: |
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Title: |
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City & State/ZIP: |
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Temp/Project |
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Employer’s Telephone No.: AC ( |
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Supervisor’s Telephone No.: |
Give average # |
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Starting Date |
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Leaving Date |
Current/ |
Technical |
AC ( |
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of hours worked per |
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Mo. |
Day |
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Yr. |
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Yr. |
Final Salary |
If supervisory, number of employees you |
week if |
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$ |
Supervisory/Managerial |
supervised: |
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Summary of experience: |
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Specific reason for leaving:
PERS 543 (02/11) |
Page 2 of 3 |
Position Title: |
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Immediate Supervisor Name: |
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Employer: |
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Mailing Address: |
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Title: |
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Summer |
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City & State/ZIP: |
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Temp/Project |
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Employer’s Telephone No.: AC ( |
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Supervisor’s Telephone No.: |
Give average # |
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Starting Date |
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Leaving Date |
Current/ |
Technical |
AC ( |
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of hours worked per |
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Mo. |
Day |
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Yr. |
Mo. |
Day |
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Yr. |
Final Salary |
If supervisory, number of employees you |
week if |
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Supervisory/Managerial |
supervised: |
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Summary of experience:
Specific reason for leaving:
Position Title: |
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Immediate Supervisor Name: |
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Employer: |
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Mailing Address: |
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Title: |
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Summer |
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City & State/ZIP: |
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Temp/Project |
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Employer’s Telephone No.: AC ( |
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Supervisor’s Telephone No.: |
Give average # |
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Starting Date |
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Leaving Date |
Current/ |
Technical |
AC ( |
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of hours worked per |
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Mo. |
Day |
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Yr. |
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Mo. |
Day |
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Yr. |
Final Salary |
If supervisory, number of employees you |
week if |
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supervised: |
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$ |
Supervisory/Managerial |
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Summary of experience: |
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Specific reason for leaving:
PERS 543 (02/11) |
Page 3 of 3 |