Form Sfn 1078 – Fill Out and Use This PDF

The SFN 1078 form, also known as the Work Activity Report - Employee, is a document issued by the North Dakota Department of Human Services Medical Assistance. It serves to collect detailed information about a claimant or beneficiary’s work activity to ascertain eligibility for Social Security Disability Insurance (SSDI) Benefits, Supplemental Security Income (SSI) Disability Benefits, or both. It is vital for individuals applying for or receiving these benefits to accurately complete and return this eight-page form to the State Review Team, as instructed, to maintain or initiate their benefits. To ensure the continuation of your benefits or to apply for them, click the button below to fill out the SFN 1078 form.

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Form Sfn 1078 PDF Details

The SFN 1078 form, formally known as the Work Activity Report - Employee ND Department of Human Services Medical Assistance, is a critical document designed for individuals applying for or receiving benefits, specifically targeting those within the purview of social security disability insurance (SSDI) and supplemental security income (SSI) disability benefits. This form, which comprises 8 pages, serves multiple purposes, including the provision of detailed information regarding the claimant's work activity post the onset of a disability or condition that impacts their ability to work. It seeks to differentiate between periods of actual work and periods where payment is received without work performance, such as sick leave or vacation pay. The form's structure is meticulously designed to capture a comprehensive overview of the claimant's employment status, work conditions, changes in work due to medical conditions, and any special work conditions or accommodations provided by the employer. Insightfully, it pushes for a granular examination of the claimant's work efforts, modifications in job roles, and the presence of any support received on the job or through special employment programs. All these layers of information are vital for the State Review Team at the North Dakota Department of Human Services, located in Bismarck, ND, to make informed decisions regarding the continuation or adjustment of the applicant’s benefits. Thus, the SFN 1078 form stands as a crucial link between the claimants' current work capabilities, their employment history, and the benefits they are entitled to, aiming to ensure a fair assessment of their situation in line with the Department's policies and guidelines.

Question	Answer
Form Name	Form Sfn 1078
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	spce, 2001, ssa 821 form no download needed, brialle

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WORK ACTIVITY REPORT - EMPLOYEE

ND DEPARTMENT OF HUMAN SERVICES

MEDICAL ASSISTANCE

SFN 1078 (Rev. 5/2005)

Note: This form has 8 pages.

IDENTIFICATION

Send to: State Review Team

ND Department of Human Services

600 E Boulevard Ave, Dept. 325

Bismarck, ND 58505

Fax: (701) 328-1544

Name of Claimant or Beneficiary

Blind

Not Blind

Name of Wage Earner (If other than Claimant or Beneficiary)

Claimant or Beneficiary is Receiving:
Social Security Disability Insurance (SSDI) Benefits	Both SSDI and SSI Disability Benefits
Supplemental Security Income (SSI) Disability Benefits	Neither SSDI or SSI Disability Benefits

	PART I - TO BE COMPLETED BY THE DEPARTMENT OF HUMAN SERVICES

1.	Please use this form to describe your work activity since	Date (to be entered by SRT)
1.	Please use this form to describe your work activity since

2.	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.)

ANSWER THE QUESTIONS ON THIS FORM AND RETURN IT AND ANY OTHER INFORMATION ABOUT YOUR CLAIM TO

THE STATEREVIEW TEAM AT THE ADDRESS LISTED IN THE UPPER RIGHT HAND CORNER OF THIS FORM.

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 If you did work, go to item 3 and answer the rest of the questions and sign and date the form.

NO 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.

2.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.

SFN 1078

Page 2

3.	TELL US ABOUT YOUR WORK SINCE THE DATE IN ITEM 1 OF PART 1 ABOVE.
3.	(If you are not sure about some things, ask your employer to help you. 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.)

Employer's Address (Include street, city, state and zip code)

	Date Work Started	Date Work Ended		Starting Hourly Pay		Current or Ending Pay

	Number of Hours Worked (on average)			Supervisor's Name		Supervisor's Telephone Number
		PER DAY	PER WEEK			(Include area code)
		PER DAY	PER WEEK

	Check each block below that is true for this work:
	I stopped working within 6 months, or I reduced my work hours and earnings within 6 months, or within 6 months I had to change the
	type of work I was doing (i.e. You were a plumber and changed to lighter work.) because
	of my medical condition.
	special conditions at work related to my medical condition that allowed me to work were removed.
	I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)

	Employer's Address (Include street, city, state and zip code)
B.

	Date Work Started	Date Work Ended		Starting Hourly Pay	Current or Ending Pay

	Number of Hours Worked (on average)			Supervisor's Name		Supervisor's Telephone Number
		PER DAY	PER WEEK			(Include area code)
		PER DAY	PER WEEK

Check each block below that is true for this work:

I stopped working within 6 months, or I reduced my work hours and earnings within 6 months, or within 6 months I had to change the type of work I was doing (i.e. You were a plumber and changed to lighter work.) because

of my medical condition.

special conditions at work related to my medical condition that allowed me to work were removed.

I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)

SFN 1078

Page 3

3.	TELL US ABOUT YOUR WORK SINCE THE DATE IN ITEM 1 OF PART 1 ABOVE.
3.	(If you are not sure about some things, ask your employer to help you. 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.)

	Employer's Address (Include street, city, state and zip code)
C.

	Date Work Started	Date Work Ended		Starting Hourly Pay		Current or Ending Pay

	Number of Hours Worked (on average)			Supervisor's Name		Supervisor's Telephone Number
		PER DAY	PER WEEK			(Include area code)
		PER DAY	PER WEEK

	Check each block below that is true for this work:
	I stopped working within 6 months, or I reduced my work hours and earnings within 6 months, or within 6 months I had to change the
	type of work I was doing (i.e. You were a plumber and changed to lighter work.) because
	of my medical condition.
	special conditions at work related to my medical condition that allowed me to work were removed.
	I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)

	Employer's Address (Include street, city, state and zip code)
D.

	Date Work Started	Date Work Ended		Starting Hourly Pay	Current or Ending Pay

	Number of Hours Worked (on average)			Supervisor's Name		Supervisor's Telephone Number
		PER DAY	PER WEEK			(Include area code)
		PER DAY	PER WEEK

	Check each block below that is true for this work:
	I stopped working within 6 months, or I reduced my work hours and earnings within 6 months, or within 6 months I had to change the
	type of work I was doing (i.e. You were a plumber and changed to lighter work.) because
	of my medical condition.

special conditions at work related to my medical condition that allowed me to work were removed.

I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)

SFN 1078

Page 4

3.	TELL US ABOUT YOUR WORK SINCE THE DATE IN ITEM 1 OF PART 1 ABOVE.
3.	(If you are not sure about some things, ask your employer to help you. 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.)

	Employer's Address (Include street, city, state and zip code)
E.

	Date Work Started	Date Work Ended		Starting Hourly Pay		Current or Ending Pay

	Number of Hours Worked (on average)			Supervisor's Name		Supervisor's Telephone Number
		PER DAY	PER WEEK			(Include area code)
		PER DAY	PER WEEK

	Check each block below that is true for this work:
	I stopped working within 6 months, or I reduced my work hours and earnings within 6 months, or within 6 months I had to change the
	type of work I was doing (i.e. You were a plumber and changed to lighter work.) because
	of my medical condition.
	special conditions at work related to my medical condition that allowed me to work were removed.
	I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)

	Employer's Address (Include street, city, state and zip code)
F.

	Date Work Started	Date Work Ended		Starting Hourly Pay	Current or Ending Pay

	Number of Hours Worked (on average)			Supervisor's Name		Supervisor's Telephone Number
		PER DAY	PER WEEK			(Include area code)
		PER DAY	PER WEEK

	Check each block below that is true for this work:
	I stopped working within 6 months, or I reduced my work hours and earnings within 6 months, or within 6 months I had to change the
	type of work I was doing (i.e. You were a plumber and changed to lighter work.) because
	of my medical condition.

special conditions at work related to my medical condition that allowed me to work were removed.

I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)

SFN 1078

Page 5

TELL US ABOUT YOUR WORK SINCE THE DATE IN ITEM 1 OF PART 1 ABOVE.

(If you are not sure about some things, ask your employer to help you. 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.)

Employer's Address (Include street, city, state and zip code)

Date Work Started

Date Work Ended

Starting Hourly Pay

Current or Ending Pay

Number of Hours Worked (on average)

Supervisor's Name

Supervisor's Telephone Number

PER DAY

PER WEEK

(Include area code)

Check each block below that is true for this work:

I stopped working within 6 months, or I reduced my work hours and earnings within 6 months, or within 6 months I had to change the

type of work I was doing (i.e. You were a plumber and changed to lighter work.) because

of my medical condition.

special conditions at work related to my medical condition that allowed me to work were removed.

I stopped working or changed the type of work I was doing for other reasons. (Tell us what the other reasons were below.)

Since the date you started working on or after the date shown in item 1of Part 1, above, have there been any months during which

you earned over $200 per month through 12/2000 or over $530 beginning 01/2001 (before anything was withheld; e.g., taxes)?

(Go to Item 5.)

Yes

(Tell us which month and year and the amount you earned that month in the chart 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.)

MONTH/YEAR

AMOUNT

MONTH/YEAR

AMOUNT

MONTH/YEAR

AMOUNT

5.SPECIAL WORK CONDITIONS - Do (Did) you get special help on-the-job or extra pay in any of the jobs that you told us about in Item 3?

NO (Go to Item 6.)

YES Check all of the boxes that are true for you and tell us for which job(s) you received that help and tell us about any other special condition(s) or help that you got on a job.

I needed and got special help from other workers	I was given a job based on my past services
in doing my job.	to an employer.
I was given special equiment or was given work	I worked irregular hours or took frequent rest periods.
that was suited to my condition.
I was allowed to work at a lower standard of	I worked in a sheltered work center.
productivity.
I worked for a relative or friend.	I was hired through a special program for training or therapy
	(e.g., vocational rehabilitation, supported employment.)

SFN 1078

Page 6

5.SPECIAL WORK CONDITIONS - Continued

Check all of the boxes that are true for you and tell us for which job(s) you received that help and tell us about any other special condition(s) or help that you got on a job.

My job duties were different than other workers' job duties doing the same work because:

I worked fewer hours.	I got different pay.
I had different duties; fewer or easier duties.	I had extra help, extra supervision, or a job coach.
I was given special transportation to and from work.	I got special help getting ready for work.

I was paid extra rest periods at work or extra time off from work and other workers were not.

Other special help. (Explain below.)

In the spce below, tell us for which job(s) you received the special help. If you need more space, use Item 9.

6.OTHER/SPECIAL PAYMENTS- Do (Did) you get any payment(s) from an employer in addition to regular pay? For example, did you get any tips, bonuses, sick or disability pay, vacation pay, meals, room or rent, transportation or use of a car or vehicle, or childcare?

	No	(Go to Item 7.)
	Yes	Tell us below what these payments were. If you need more space, use Item 9.

		EMPLOYER	TYPE OF PAYMENT	AMOUNT OR ESTIMATE	MONTH & YEAR
		EMPLOYER	TYPE OF PAYMENT	OF THE DOLLAR VALUE	MONTH & YEAR
				OF THE DOLLAR VALUE
				$

				$

				$

				$

				$

7.	SPECIAL WORK EXPENSES (IMPAIRMENT-RELATEDWORK EXPENSES) - Do (Did) you spend any money of your own earnings
7.	for any things or services related to your condition that allowed you to work and for which you did not get paid back?

For example, medicines, bandages, braces, wheelchair, artificial arm or leg, brialle equipment, special telephone or computer equipment, modifications to home (wider dorrways, roll-in shower, ramps, wheelchair-lift), or modifications to a car (automatic wheelchair-lift), personal assistance (personal care attendant.)

No	Go to Item 8.
Yes	Tell us below about the bills, or part of the bills, that you paid for things or services related to your medical condition
	that you needed in order to work. (Upon review, you may be required to provide proof of these expenses.) Do not
	show any bills or amounts paid by an insurance company or any other organization or person or paid to you by an
	insurance company or other organization or person. (Example: An insurance company might pay all or part of the bill
	at a later time.)

SFN 1078

Page 7

7.SPECIAL WORK EXPENSES (IMPAIRMENT-RELATEDWORK EXPENSES) - Continued

ITEM OR SERVICE	COST	DATE(S) PAID (MONTH & YEAR)

	$

	$

	$

	$

	$

	$

SPECIAL TRANSPORTATION	COST	DATE(S) PAID (MONTH & YEAR)

MODIFIED VEHICLE	$

TAXI-TYPE SERVICE	$

8.VOCATIONAL REHABILITATION- Are (Were) you getting any help from a vocational rehabilitation or employment services provider to get the services and/or training you need to get ready to start working, find work or keep working?

	No	If you answered no, would you like to get these services?			Yes	No (Go to Item 10.)
	Yes	Tell us the name and address of the people who are (were) giving you vocational rehabilitation or employment
		services and training.

			Vocational Rehabilitation/Employment Services Provider

	Name			Address (Include street, city, state & zip)

	Counselor's Name			Counselor's Telephone Number (Include area code)

			If you need more space, go to Item 9, below.

9.	More Space. For any question above, if you need more space, use the space below. Remember to write the number of the question that
9.	you are answering before you begin.

SFN 1078 Page 8

More Space - (Continued) For any question above, if you need more space, use the space below. Remember to write the number of the question that you are answering before you begin.

10.

I authorize any employer, agency or other organization to disclose to the State agency who may determine or review my entitlement to disability benefits any information about my medical condition or my work.

SIGN AND DATE THIS FORM

I certify under penalty of law that the information on this form is true.

Signature of Claimant, Beneficiary or Representative	Date
Signature of Claimant, Beneficiary or Representative

Address (Include street, city, state and zip code)	Telephone Number

Witness must sign ONLY if this statement is signed by mark (i.e., X) above. If signed by mark (X), two witnesses to the signing who know the person making the statement must sign below, giving their full addresses and telephone numbers.

1. Signature of Witness	2. Signature of Witness

Address (Include street, city, state and zip code)	Address (Include street, city, state and zip code)
	Address (Include street, city, state and zip code)

Telephone Number

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1OF completion process detailed (stage 1)

2. The third stage is usually to fill out these particular blank fields: HAVE YOU WORKED SINCE THE DATE, YES, If you did work go to item and, If you did not work but earnings, REPORT WORK OR EARNINGS, If you did not work but earnings, For example sometimes pay is sick, If you cant explain the earnings, and Explanation of Earnings.

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