Pennsylvania County Assistance Offices use this form to document a physical or mental disability that keeps a public assistance applicant or recipient from any gainful employment. The examining provider classifies the person as permanently disabled, temporarily disabled for 12 months or more or for less than 12 months, or employable, and explains the basis. The form, which still refers to General Assistance, says benefits cannot be authorized until the fully completed form is back with the CAO worker.
The applicant or recipient completes Section I, explaining why they believe they cannot work and signing the release. Only a licensed physician (MD or DO), physician assistant, certified registered nurse practitioner or psychologist who performed the assessment completes and signs Section II.
The first page, headed please read instructions before completing form, sets the ground rules. Only a licensed physician, physician assistant, certified registered nurse practitioner or psychologist may perform the assessment, and only that person may sign, with an original signature. Entries and attachments must be complete and legible, typed if possible. Incomplete or unreadable forms delay the client's application and are returned for completion.
The client checks the printed name, birthdate, Social Security number, address and phone, corrects anything wrong, and briefly explains why they believe they cannot work. They sign and date an authorization for all medical providers to release information related to their employability to DHS, used only to assess their ability to work and eligibility. The client then makes the appointment with you.
Check only one employability block. Block 1 means a physical or mental disability permanently precludes any gainful employment. The instructions require a medically determinable impairment arising from anatomical, physiological or psychological abnormalities shown by medically acceptable clinical and laboratory techniques, and established by signs, symptoms and laboratory findings, not only the patient's statement. The form notes the patient is a candidate for Social Security Disability or SSI.
Blocks 2 and 3 are for an injury or acute condition that temporarily precludes any gainful employment: block 2 if it is expected to last 12 months or more, block 3 if less than 12 months. Enter the date the disability began and the date it is expected to end, which is when the client is expected to be able to work. Check block 4, employable, when neither disability block fits.
Both parts must be completed if block 1, 2 or 3 is checked, or the client is ineligible. Item 1 asks for the primary and secondary diagnosis. Item 2 asks what the assessment is based on: physical examination, review of medical records, clinical history, appropriate tests and diagnostic procedures, or other (specify). The instructions say this section must clearly establish the basis for your decision, and supporting documentation must be available for review.
By signing, you certify that you read and complied with the instructions, that the information is true and correct to the best of your knowledge, and that your diagnosis and assessment rest solely on the patient's condition as determined by your examination. You also agree that DHS may review your diagnosis and documentation. Print your name, phone and address, enter your Medical Assistance provider number, sign in original ink and date.
Download the current version from the source each time; forms change without notice.
Employability Assessment Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Only a licensed physician (medical doctor or doctor of osteopathy), physician assistant, certified registered nurse practitioner or psychologist may perform the assessment, and only the individual who performed it may sign. The signature must be original; signature stamps, clinic stamps, labels and other facsimiles are not acceptable and invalidate the form.
Both cover an injury or acute condition that temporarily prevents any gainful employment, and both ask when the disability began and when it is expected to end. Check the 12 months or more block if you expect it to last at least a year; the form notes such a patient may be a candidate for Social Security Disability or SSI.
No. The PA 1663 is the Employability Assessment Form, and its instructions still refer to General Assistance. The DHS Cash Assistance Handbook says the PA 635 Medical Assessment Form must be used to verify disability for TANF, including exemptions from employment and training requirements. Complete whichever form the County Assistance Office sends with the client.
The instructions ask that the form and any attachments be typed if possible. If county staff cannot read your entries, the client's application is delayed and the form comes back to you for clarification, and any question not fully answered has the same result.