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OJT COMPLETION CHECKLIST
*Place all monitoring reports in file. Rev. 06/19
Trainee: Job Title:
Company: Contract#: Employer ID #:
Contact Name: Phone #: Email:
Address:
City: State: Zipcode:
Contract Completion Checklist
Task Initial Date
1. Addendum A: Pre-Award Review Business Application
2. Addendum B: Responsibility Questionnaire Attestation Form (90 Days)
3. Addendum C: Business Data Information
4. Due Diligence Request
5. Due Diligence Approval
6. Division of Corporations, OSHA, Workman’s Comp.
7. Grievance Waiver/EEO Form for Trainee
8. Training Outline
9. Individual Employment Plan
10. Addendum D: Individual Training Program (ITP)
11. Dislocated Worker Certification
12. Supplemental Questionnaire
13. Copy of trainee license/government issued ID/ other birth verification document
14. DEV & Selective Service information entered (Attestation Form)
15. Job Zone Skills Gap Analysis
16. Addendum E: Contract (include Federal certifications) review of reimbursement.
17. Addendum F: Contract Modification
18. Services and Training “Additional Info” tab O*NET title entered
19. Addendum G: Trainee Monitoring Report (I, II, III) – wage verification
20. Addendum H: Employer Monitoring Report (I,II, III) – wage verification
21. Third monitoring at completion of OJT – wage verification. Verify skill set attained.
22. Collect reimbursement forms, timesheets, payroll – verify wage
23. OSOS close
FOR
OFF
ICE
USE
ON
LY
ADDENDUM A – PRE‐AWARD REVIEW BUSINESS APPLICATION
Rev. 6/2017
Trainee: Job Title:
Company: Contract#: Employer ID #:
Contact Name: Phone #: Email:
Address:
City: State: Zipcode:
Instructions: Please complete all items on this application. To facilitate your review, please prepare this application electronically.
Business Information
Name:
Address 1:
Address 2:
City: State: Zip:
FEIN: NAICS: DUNS:
Previous name of business, if any:
FEIN, if different:
Contact Person
Name:
Title:
Phone Number:
Fax Number:
Email Address:
Business Background
Has your company relocated from another area in the U. S. within the last 120 days?
Yes
No
If so, were there any employees laid off at that former location?
How long have you been in business is this area?
How many full‐time employees do you have?
Are any employees on layoff currently? Yes
No
If so, how many employees and in what job titles?
FOR OFFICE USE ONLY
ADDENDUM A – PRE‐AWARD REVIEW BUSINESS APPLICATION
Rev. 6/2017
Have any WARN notices been filed within the past year? Yes
No
Has your business sought WIA/TGAA or other assistance in connection with past or impending job losses at other facilities during the past year?
Yes
No
What job titles/job descriptions are you seeking to fill with OJT trainees? (use the job description form provided – can attach existing job descriptions in lieu of completing job description section in the form)
Are all job openings in New York State? Yes
No
Are any of the jobs considered for an OJT candidate classified as “independent contractor” positions, or would individuals not be employed by your firm during the entire training period?
Yes
No
Are any of the jobs covered by a collective bargaining agreement? (If so, we will need to obtain a letter of concurrence from the union(s))
Yes
No
Is your business currently engaged in any labor disputes with a labor organization? Yes
No
Do any of the jobs pay based upon commissions, tips, piece work or incentives? If yes, please explain:
Yes
No
What percentage of previous trainees, over the last two (2) years, have completed training and been retained by your firm?
Number of OJT trainees:
Number of OJT employees retained:
Percentage retained:
Business Applicant Signature
PRINT NAME TITLE
SIGNATURE DATE
ADDENDUM B – OJT EMPLOYER RESPONSIBILITY QUESTIONAIRE & ATTESTATION
Signed original form or fax/PDF must be provided to the WIB office prior to entering into any OJT contract.
Rev. 6/2017
Trainee: Job Title:
Company: Contract#: Employer ID #:
Contact Name: Phone #: Email:
Address:
City: State: Zipcode:
Instructions: Please answer all questions. A “Yes” answer to any part of questions 1‐5 requires a written explanation to
be prepared on company letterhead, signed by an officer of the company, and attached to the completed questionnaire.
1. Within the past five years, has your firm, any affiliate (1), any principal, owner or officer or major stockholder
(10% or more shares) or any person involved in the bidding or contracting process been the subject of any of the
following:
a. A judgement or conviction for any business‐related conduct constituting a crime under local, state, or
federal law including, but not limited to, fraud, extortion, bribery, racketeering, price‐fixing, or bid
collusion or any crime related to truthfulness and/or business conduct?
Yes No
b. A criminal investigation or indictment for any business‐related conduct constituting a crime under local,
state, or federal law including, but not limited to, fraud, extortion, bribery, racketeering, price‐fixing, or
bid collusion or any crime related to truthfulness and/or business conduct.
Yes No
c. An unsatisfied judgement, injunction or lien obtained by a government agency including, but not limited
to, judgements based on taxes owed and fines and penalties assessed by any local, state, or federal
government agency?
Yes No
d. Any investigation for a civil violation for any business‐related conduct by any local, state, or federal
agency?
Yes No
e. A grant of immunity for any business‐related conduct constituting a crime under local, state, or federal
law including, but not limited to, fraud, extortion, bribery, racketeering, price‐fixing, or bid collusion or
any crime related to truthfulness and/or business conduct?
Yes No
FOR OFFICE USE ONLY
ADDENDUM B – OJT EMPLOYER RESPONSIBILITY QUESTIONAIRE & ATTESTATION
Signed original form or fax/PDF must be provided to the WIB office prior to entering into any OJT contract.
Rev. 6/2017
f. A local, state, or federal suspension or termination from contracting process?
Yes No
g. A local, state, or federal contract suspension or termination for cause prior to the completion of the
term of contract?
Yes No
h. A local, state, or federal denial of a lease or contract award for non‐responsibility?
Yes No
i. An agreement to voluntary exclusion from bidding/contracting?
Yes No
j. An administrative proceeding or civil action seeking specific performance or restitution in connection
with any local, state or federal contract or lease?
Yes No
k. A local, state, or federal determination of a willful violation of any prevailing wage law or a violation of
any other labor law or regulation?
Yes No
l. A sanction imposed as a result of judicial or administrative proceedings relative to any business or
professional license?
Yes No
m. A denial, decertification, revocation, of forfeiture of Women’s Business Enterprise, Minority Business
Enterprise or Disadvantaged Business Enterprise status.
Yes No
n. A rejection of a low bid on a local, state, or federal contract for failure to meet statutory affirmative
action of MWBE requirements on previously held contract?
Yes No
o. A consent order with the New York State Department of Environmental Conservation, or a federal, state,
or local government enforcement determination involving a violation of a federal, state or local
government laws?
Yes No
ADDENDUM B – OJT EMPLOYER RESPONSIBILITY QUESTIONAIRE & ATTESTATION
Signed original form or fax/PDF must be provided to the WIB office prior to entering into any OJT contract.
Rev. 6/2017
p. An Occupational Safety and Health Act citation and Notification of Penalty containing a violation
classified as serious or willful?
Yes No
q. A rejection of a bid on a New York contract or lease for failure to comply with the MacBride Fair
Employment Principles?
Yes No
r. A citation, notice, violation order, pending administrative hearing or proceeding or determination for
violations of:
Federal, state, or local health laws, rules, or regulations
Unemployment insurance or workers’ compensation coverage or claim requirements
ERISA (Employee Requirement Income Security Act)
Federal, state, or local human rights laws
Federal or state security laws
Federal INS and Alienage laws
Sherman Act or other federal anti‐trust laws?
Yes No
s. A finding of non‐responsibility by an agency or authority due to the failure to comply with the
requirement of Tax Law Section 5‐a?
Yes No
2. Has the vendor been the subject of agency complaints or reports of contract deviation received within the past
two years for contract performance issues arising out of a contract with any federal, state, or local agency? If
yes, provide details regarding the agency complaints or reports of contract deviation received for contract
performance issues.
Yes No
3. Does the vendor use, or has it used in the past five (5) years, an Employee Identification No., Social Security No.,
Name, DBA, trade name or abbreviation different from that listed on your mailing list application form? If yes,
provide the name(s), FEIN(s), and d/b/a(s) and the address for each such company and d/b/a on a separate
piece of paper and attach to this response.
Yes No
ADDENDUM B – OJT EMPLOYER RESPONSIBILITY QUESTIONAIRE & ATTESTATION
Signed original form or fax/PDF must be provided to the WIB office prior to entering into any OJT contract.
Rev. 6/2017
4. During the past three (3) years, has the vendor failed to file returns or pay any applicable local, state, or federal
governmental taxes?
Yes No
If yes, identify the taxing jurisdiction, type of tax, liability year(s) and tax liability amount the company failed to
file/pay and the current status of the liability:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
5. During the past three (3) years, has the vendor failed to file returns or pay New York State Unemployment
Insurance?
Yes No
If yes, indicate the years the company failed to file/pay the insurance and the status of the liability:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
6. Have any bankruptcy proceedings been initiated by or against the vendor or its affiliates within the past seven(7)
years (whether or not closed) or is any bankruptcy proceeding pending by or against the vendor or its affiliates,
regardless of the date of filing?
Yes No
If yes, indicate if this is applicable to the submitting vendor or one of its affiliates:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
If it is an affiliate, include the affiliate’s name and FEIN:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Provide the court name, address and docket number:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
ADDENDUM B – OJT EMPLOYER RESPONSIBILITY QUESTIONAIRE & ATTESTATION
Signed original form or fax/PDF must be provided to the WIB office prior to entering into any OJT contract.
Rev. 6/2017
Indicate if the proceedings have been initiated, remain pending or have been closed:
___________________________________________________________________________________________
___________________________________________________________________________________________
If closed, provide the date closed:
_________________________________________________________________________
1 “Affiliate” meaning: (a) any entity in which the vendor owns more than 50% of the voting stock; (b) any individual, entity or group of principal
owners who own more than 50% of the voting stock of the vendor; or (c) any entity whose voting stock is more than 50% owned by the same
individual, entity or group described in clause (b). In addition, if a vendor owns less that 50% of the voting stock of another entity, but directs or has
the right to direct such entity’s daily operations, that entity will be an “affiliate” for the purposes of this questionnaire.
ADDENDUM B – OJT EMPLOYER RESPONSIBILITY QUESTIONAIRE & ATTESTATION
Signed original form or fax/PDF must be provided to the WIB office prior to entering into any OJT contract.
Rev. 6/2017
ATTESTATION FORM / CERTIFICATION:
The undersigned: recognizes that this questionnaire is submitted for the express purpose of assisting the State of New
York or is agencies or political subdivisions to make a determination regarding the award of a contract or approval of a
subcontract; acknowledges that the State or its agencies and political subdivisions may in its discretion, by means which
is may choose, verify the truth and accuracy of all statements made herein; acknowledges that intentional submission of
false or misleading information may constitute a felony under Penal Law Section 210.40 or a misdemeanor under Penal
Law Section 210.35 or Section 210.45, and may also be punishable by a fine of up to $10,000 or imprisonment of up to
five years under 18 USC Section 1001 and may result in contract termination; and states that the information submitted
in this questionnaire and any attached pages is true, accurate, and complete.
The undersigned certifies that he/she:
Has not altered the content of the questions in the questionnaire in any manner;
Has read and understands all of the items contained in the questionnaire and any pages attached by the
submitting vendor;
Has supplied full and complete responses to each item therein to the best of his/her knowledge, information
and belief;
Is knowledgeable about the submitting vendor’s business and operations;
Understands that New York State will rely on the information supplied in this questionnaire when entering into a
contract with the vendor; and
Is under a duty to notify the procuring State Agency of any material changes to the vendor’s responses herein
prior to the State Comptroller’s approval of the contract.
NAME OF BUSINESS SIGNATURE OF OFFICER
ADDRESS DATE
CITY, STATE, ZIP TYPED NAME AND TITLE
Principal place of business if different from address above (include complete address)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ADDENDUM C – OJT BUSINESS DATA SHEET
Rev. 6/2017
Trainee: Job Title:
Company: Contract#: Employer ID #:
Contact Name: Phone #: Email:
Address:
City: State: Zipcode:
Company Information
Company Name:
Type of Business and Main Product:
FEIN: NAICS: DUNS:
Legal Status Corporation Partnership Sole Proprietorship
Other (Identify):
Minority Ownership: Yes
No
Number of years business in operation:
Women Owned: Yes
No
How long in this location?
Worker’s Compensation Insurance Company:
Name:
Policy Number: Coverage Dates:
List Unions and Name of Representatives:
Has this employer participated in funded OJT contracts in the past? Yes
No
If “YES”, please identify:
Number of Contracts:
Number of Trainees:
Funding Sources:
Retention/Outcomes:
Workforce Information
Total Workforce: Turnover Last Year:
Workforce at Training Site:
Ratio of Trainees to Employees:
Pay Schedule: Weekly Bi‐Weekly Semi‐Monthly Other (Specify)
Pay Day:
Period Covered:
Employee Performance Reviews are Completed:
6‐months Annually Other (Specify)
Which of the following are required at the time of hire?
Driver’s License Chauffeur’s License
Own Transportation
Is public transportation available at the worksite?
Yes
No
Is the worksite handicap accessible?
Yes
No
FOR OFFICE USE ONLY
ADDENDUM C – OJT BUSINESS DATA SHEET
Rev. 6/2017
Company Policy Information
Does the company have the following (if “YES”, please attach copies for verification.)
Apprenticeship Training Program Yes
No
EEO/Affirmative Action Plan Yes
No
Written Grievance Procedures Yes
No
Personnel Policies and Procedures Yes
No
When are these company policies reviewed with employees?
Upon hire First day of work
Other (specify)
Are policies reviewed individually or within group setting (i.e. orientation)?
Individually Group Setting
Employee Benefits Information
The trainee must be provided benefits to the same extent as the employer’s regular employees. Please indicate the benefits to be provided.
Medical Insurance %paid by employee: Available:
Life Insurance %paid by employee: Available:
Holiday Leave %paid by employee: Available:
Sick Leave %paid by employee: Available:
Vacation Leave %paid by employee: Available:
Retirement Benefits Type:
Available:
%paid by employee:
Employer Match Yes
No
Other (specify)
Authorized Signatory(s) information
Name & title of official authorized to sign contracts & modifications
Name & title of official authorized to sign timesheets
Other Company Contact Information
Name & title of accounts payable representative
Name & title of human resource representative
ADDENDUM D – OJT INDIVIDUAL TRAINING PLAN
Rev. 6/2017
Trainee: Job Title:
Company: Contract#: Employer ID #:
Contact Name: Phone #: Email:
Address:
City: State: Zipcode:
Funding: Adult DW NEG Youth Other:
Section 1: Contact and OJT Information – complete the contact information for the Employer and the Trainee.
Employer Name: Type of Business:
Contact Person: Email: Telephone #:
Trainee Name: Email: Telephone #:
Statement of Training Need:
Beginning Date: End Date: Total Training Hours:
Hourly Wage Rate: $ Reimbursement Rate: % Maximum Reimbursement: $
Training Supervisor: Email: Telephone #:
Primary Trainer: Secondary Trainer:
Others Providing Training:
Section 2: Occupational Information – Complete the occupational information of the Trainee’s skill level
Job Title: O*Net Soc #: Hours/Week:
Supervisor:
Job Description:
Required Job Skills for Occupation Starting Capability:
Date Measured:
1. Job Skill Needed: Not Skilled
Some Skill
Skilled
FOR OFFICE USE ONLY
ADDENDUM D – OJT INDIVIDUAL TRAINING PLAN
Rev. 6/2017
2. Job Skill Needed: Not Skilled
Some Skill
Skilled
3. Job Skill Needed: Not Skilled
Some Skill
Skilled
4. Job Skill Needed: Not Skilled
Some Skill
Skilled
5. Job Skill Needed: Not Skilled
Some Skill
Skilled
6. Job Skill Needed: Not Skilled
Some Skill
Skilled
Section 3: Training Information: Complete the training outline and estimated time for each skill.
Skills To Be Learned: Training Methodology Estimated Training Hours End Capability
Date Measured
1. Skill To Be Learned: Demonstration
Explanation
Classroom
Other _________________
Estimated Training Hours: Beginning
Intermediate
Skilled
2. Skill To Be Learned: Demonstration
Explanation
Classroom
Other _________________
Estimated Training Hours: Beginning
Intermediate
Skilled
ADDENDUM D – OJT INDIVIDUAL TRAINING PLAN
Rev. 6/2017
3. Skill To Be Learned: Demonstration
Explanation
Classroom
Other _________________
Estimated Training Hours: Beginning
Intermediate
Skilled
4. Skill To Be Learned: Demonstration
Explanation
Classroom
Other _________________
Estimated Training Hours: Beginning
Intermediate
Skilled
5. Skill To Be Learned: Demonstration
Explanation
Classroom
Other _________________
Estimated Training Hours: Beginning
Intermediate
Skilled
6. Skill To Be Learned: Demonstration
Explanation
Classroom
Other _________________
Estimated Training Hours: Beginning
Intermediate
Skilled
LIST SUPPLIES AND TOOLS NEEDED FOR TRAINING:
Section 4: Authorized Signatures
All parties agree to provide or obtain training for the skills outlined in this Training Plan.
EMPLOYER SIGNATURE
TRAINEE SIGNATURE OJT PROVIDER SIGNATURE
PRINT NAME/TITLE
PRINT NAME/TITLE PRINT NAME/TITLE
DATE
DATE DATE
ADDENDUM D – OJT INDIVIDUAL TRAINING PLAN
Rev. 6/2017
TRAINING PLAN INFORMATION AND INSTRUCTIONS
Training Plans are used to outline the specific skill requirements for on‐the‐job training (OJT). They are also used as the assessment tool to document which skills the Trainee
lacks at the start of the training and to measure skill attainment during the course of the training.
Job Description: A job description may be obtained from the Employer or the OJT Provider may assist the employer in writing a job description, thus providing a “value‐added”
for the employer. For assistance in writing a job description you may use the tasks and activities provided at the CareerOneStop Job Description Writer
(www.careerinfonet.org/jobwriter/). Please modify these descriptions to be specific to the employer’s needs for the occupation.
Skill Requirements: List the skills needed to perform the job to the standards specified by the Employer. Record skills as specifically and briefly as possible. For assistance in
writing skill requirements you may use the tasks and activities provided at )*NET OnLine (http://online.onetcenter.org). Please modify these skills to be specific to employer’s
needs for the occupation. (Type of tools or software used).
Trainee’s Starting Capability: Used to assess the trainee’s skill level near the beginning of the training period and to document skill definicencies which will be addressed
through training. The skills gap can be addressed in the list of “Skills to be learned.” The “Starting” and the “Ending Capability” scores are based upon an interview with the
Trainee’s supervisor or by utilizing another skill assessment method used by the employer.
Trainee’s Ending Capability: Record the date on which the “Ending Capability” assessment is made and the skill level which has been obtained using the following rating scale:
1. Beginning – Can only do simple parts of the task.
2. Intermediate – Can do most parts of the task.
3. Skilled – Meets the Employer’s standard for the task.
Training Length:
a. The OJT Provider, working with the Employer, determines the job title for the position to be trained for, referencing O*NET OnLine (http://online.onetcenter.org).
b. From O*NET OnLine, Job Zone/SVP parameters are obtained. Use these parameters as a beginning guide to determine the length of training.
c. The OJT Provider considers the trainee’s past work experience, knowledge, and skills gap to assist in determining the length of training.
d. An OJT contract must be limited to the period of time required for a participant to become proficient in the occupation for which the training is being provided. In
determining the appropriate length of the contract, consideration should be given to the skill requirements of the occupation, the academic and occupational skill level
of the participant, prior work experience, and the participant’s individual employment plan.
e. It may be necessary to deviate from the training schedule, depending on the trainee’s ability to gain and retain knowledge of the various tasks within the occupation. If
there is disruption of the planned training period through no fault of the trainee or the employer, provide modifications in writing with the Training Plan Modification
Template.
Rev: 6/2017
ADDENDUM E – OJT TRAINING CONTRACT
Trainee: Job Title:
Company: Contract#: Employer ID #:
Contact Name: Phone #: Email:
Address:
City State: Zipcode:
BUFFALO AND ERIE COUNTY WORKFORCE DEVELOPMENT CONSORTIUM, INC. (WDC)
and
____________________________________________________________________________________________
(Name, Address and Phone Number of Company / Organization “The contractor”)
ON THE JOB TRAINING COST SUMMARY
EMPLOYEE JOB TITLE TRAINEE NAME REIMBURSEMENTWAGE/HOUR
NUMBER OFTRAINING HOURS
RATE TOTAL
XXXX XXXXX $XX.XX xxxx XX% $XXXX.XX
These parties hereto agree that the training period of the employee(s) trained under this Agreement shall begin on or after and shall end no later than ___________________and shall not exceed the number of training hours authorized by the Buffalo and Erie County Workforce Development Consortium. Inc. (WDC) Director of Business Services. No individual(s) shall be trained for any job title identified under this Agreement prior to the beginning date of this Agreement, or prior to their being certified eligible to participate in this program. The WDC reserves the right to reduce the amounts above to an amount sufficient for the anticipated cost of training that will be completed by the end date and invoiced in accordance with Provisions fourteen (14) and fifteen (15) of this Contract. The WDC will notify the contractor in writing of any such change in the amounts obligated herein. The undersigned representatives of the Contractor and the WDC agree to comply with and adhere to this Contract, including its Provisions and Attachments, which are hereby incorporated and made a part of this Contract.
Contractor Certification IN WITNESS WHEREOF, the Contractor has caused this instrument to be signed by its
WDC Certification IN WITNESS WHEREOF, the WDChas caused this instrument to be signed by its
Administrator Director thereunto duly authorized (Title) thereunto duly authorized
Lavon Stephens (please print name) (please print name)
(signature) (date) (signature) (date)
(Notary) (Commissioner of Deeds)
(Notary) (Commissioner of Deeds)
Rev: 6/2017
ADDENDUM E – OJT TRAINING CONTRACT
Is / Are the job title(s) listed in this Agreement covered under a Collective Bargaining Agreement?
Yes ___________ No ____________
If yes, the undersigned representative of the Collective Bargaining Unit concurs with the provisions of this On‐The‐Job Training Contract. Collective Bargaining Unit Name: Representative Name: ______________________________ Signature: ________________________________________ Date: __________________
Funds for job training under this contract have been made available to the Bu f f a l o and E r i e Coun t y Workforce Development Consortium, Inc. (WDC) through the Workforce Innovation and Opportunity Act (WIOA), or other sources. WIOA enables the WDC to provide employers with payments to help offset the costs of training employees on the job. WIOA eligible trainees are hired by the employer who provides them with training in accordance with a written agreement and approved training outline. WIOA or other funds are then provided to the employer under the terms of this agreement to cover part of the cost of training the employee through the WDC. The WDC has been designated by the Erie County Executive and the Mayor of the City of Buffalo as the Grant Sub‐recipient and Fiscal Agent for Workforce Investment Act funds in Buffalo and Erie County.
PROVISION 1.) The parties hereto agree that the Contractor shall provide all on the job training for the job title(s) listed in this
Agreement and shall furnish all instruction, supervision, materials, equipment and supplies necessary to insure the proper and adequate training of the employee(s) hired under this Agreement.
2.) The Contractor agrees to provide supervision and training to any employee(s) under this Agreement in accordance
with the request for on‐the‐job training authorization, attached as Attachment A, and made a part of this agreement.
3.) The Contractor agrees to provide this training at the site as authorized by the WDC Director of Business Services.
4.) The parties agree that (an) employee(s) will be hired and begin training within___5___days of the beginning date of this Agreement. If an employee(s) is/are not hired for the job title(s) listed in the Agreement within__5__days of the beginning date of the Agreement, a new contract must be executed to cover any of the remaining position(s) if they are to be filled.
5.) The Contractor agrees to place any employee(s) trained under this Agreement on the Contractor’s regular payroll
and agrees to provide the employee(s) hired under this agreement with the same benefits and privileges offered to similarly employed individuals within the Contractor’s company/organization.
6.) The Contractor certifies that no trainee under this contract shall be employed in the construction, operation,
or maintenance of any facility that is used, or will be used, for sectarian instruction or a place of religious worship, or in any secretarial, clerical, maintenance or tutoring assignments involving any sectarian activities or duties. Additionally, no trainee shall be placed in any capacity at any workstation or free any other person for the performance or rendering of such duties.
Rev: 6/2017
ADDENDUM E – OJT TRAINING CONTRACT
7.) The Contractor certifies that no person shall be excluded from participation in this training, be denied benefits,
or be subjected to discrimination in employment because of race, color, re l ig ion, gender, national origin, age, disability, material status, or past convictions (unless the conviction is related to the prospective job.)
8.) The Contractor agrees to maintain adequate records, including payroll and attendance records for any employee(s) hired under this Agreement, and to make such records available for review by the WDC, its agents or funding sources.
9.) The Contractor agrees to comply with all applicable employment‐related federal, state and local rules,
regulations, and policies including those governing safety and health, payment of worker’s compensation, and job‐training program funded under WIOA.
10.) The Contractor agrees to inform any employee(s) hired under this Agreement of the grievance procedures followed
by the Contractor. If no grievance procedures are in place, the Contractor understands that any employee hired under this Agreement has the right to follow the grievance procedures of the WDC. Disputes between the contractor and the WDC may also be resolved through the WDC and/or WIOA grievance procedures.
11.) The Contractor certifies that there is a reasonable expectation of continued employment within the Contractor’s
company/organization for persons successfully completing the training period of the job title(s) listed in the Agreement. 12.) The Contractor shall notify the WDC, in writing, of the voluntary or involuntary termination or lay off of any
of the employee(s) trained under Agreement within five (5) working days of such termination. 13.) The Contractor certifies that no employee(s) trained under this Agreement will take the place of any employee(s)
of the Contractor’s company/ organization who is/are on lay‐off.
14.) The WDC agrees to pay all properly incurred costs to the Contractor as provided for under the heading ON THE
JOB TRAINING COST SUMMARY. Reimbursement of wages will be made to the Contractor upon submission of properly executed invoices using the invoice form shown in Attachment B or other form approved by the WDC.
15.) The Contractor understands that failure to submit a final invoice within forty‐five (45) calendar days either of the
completion of the training or of the termination of an employee(s) covered under this agreement will result in the forfeiture of the of balance of the payment due under this agreement to the contractor.
16.) The Contractor further agrees to post all employment opportunities at their company with the WDC for the period
of one (1) year from the initiation of this contract. The WDC will identify and refer appropriate candidates for these positions to the Contractor for employment consideration. This will be done at no cost to the Contractor who will retain the right to determine whether further action on each referral is appropriate.
17.) The parties agree that this contract may be terminated at any time due to failure of the Contractor to adhere to any
of the provisions of this Contract, or at the sole discretion of the WDC. 18.) When hiring under a qualified job‐training program funded in whole or in part by the U.S. Department of Labor, the
Contractor agrees to give priority status to equally qualified veterans and spouses of certain veterans. 19.) The Contractor agrees that when using WIOA funds to purchase any equipment, goods or products, to the greatest
extent practicable, equipment, goods and products manufactured in the USA will be purchased. 20.) The Contractor agrees that this OJT contract will not infringe in any way upon the promotional opportunities of
current employees not involved OJT.
Rev: 6/2017
ADDENDUM E – OJT TRAINING CONTRACT
21.) The Contractor agrees that funds provided under this contract to reimburse the costs associated with OJT will not be
used to assist, promote or deter union organizing. 22.) The Contractor agrees that training activities provided under this contract will not impair an existing contract for
services or collective bargaining agreement, and/or no activity that would be inconsistent with the terms of a collective bargaining agreement shall be undertaken without written concurrence of the labor organization and the business.
23.) The Contractor agrees that no member of the OJT employee’s immediate family will directly supervise the OJT
employee, nor will the trainee supervise an immediate family member. For the purpose of this contract, immediate family is defined as spouse, children, parents, grandparents, grandchildren, brothers, sisters or persons bearing the same relationship to the OJT employee’s spouse.
24.) The Contractor agrees to provide a Drug Free Workplace by implementing the provisions at 29 CFR 94 pertaining to
a Drug Free Workplace. 25.) The Contractor agrees that funds provided under this contract to provide specific training to a specific individual will
not be used to pay salaries or bonuses of any other person 26.) The Contractor agrees and is clear that if one person quits before completing the training period, the balance of the
monies cannot be shared by the other trainee. Funding for this contract is provided by the United States Department of Labor, which requires the following certifications:
A. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion – Lower Tier Covered Transactions. The Contractor certifies that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation in this action by any Federal department or agency. Where the Contractor is unable to certify to any of the statements in this certification, the contractor shall attach an explanation to this contract.
B. Certification Regarding Lobbying.
Contractor certifies to the best of his/her knowledge and belief that: No Federally appropriated funds have been paid or will be paid, by or on behalf of the Contractor, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering in to of any cooperative agreement, and the extension, continuation, renewal, amendment or modification of any Federal contract, loan, grant or cooperative agreement.
If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this contract, or another Federal contract, loan, grant or cooperative agreement, the Contractor shall complete and submit a Disclosure Form to Report Lobbying.
C. Certification Regarding Clean Air Act and the Federal Water Pollution Act, as amended. Contractor certifies that if the amount of this Contract is in excess of $100,000.00, Contractor will comply with all applicable standards, orders or regulations issued pursuant to the Clean Air Act, (42 U.S.C. §7401 et seq.) and the Federal Water Pollution Act, as amended (33 U.S.C. §1251 et eq.).
Rev: 6/2017
ADDENDUM E – OJT TRAINING CONTRACT
D. Energy Policy and Conservation Act
Contractor certifies that it will comply with the mandatory standards and policies relating to energy efficiency contained in the state energy conservation plan issued in compliance with the Energy Policy and Conservation Act (42 U.S. C. 6201).
E. Certification Regarding Construction Contracts.
Contractor certifies that if this contract involves construction services financed in whole or in part with loans or grants from the United States, Contractor will comply with the Copeland Anti‐Kickback Act (18 USC §874), the Davis Bacon Act (40 USC §276a to a7) and the Contract Work Hours and Safety Standards Act (40 USC §327‐333), and the applicable regulations thereunder.
E. Certification Regarding Rights to Inventions under a Federal Funding Agreement under 37 CFR Section 401.2
Contractor certifies that if this Contract is a federal funding agreement, Contractor will comply with the “Rights to Inventions made by Nonprofit Organizations and Small Business Firms under Government Grants, Contracts and Cooperative Agreements (37 CFR Part 401.2 (a)), and the applicable regulations thereunder.
F. Certification Regarding Procurement of Recovered Materials under the Solid Waste Disposal Act.
Contractor certifies that if this Contract is for the procurement of recovered materials, Contractor will comply with Section 6002 of the Solid Waste Disposal Act, as amended by the Resource Conservation and Recovery Act, and the applicable regulations thereunder.
For more information regarding this Agreement, please contact:
Buffalo and Erie County Workforce Development Consortium, Inc. Business Services Division
(716) 819‐9845
ADDENDUM F – OJT CONTRACT MODIFICATION
Rev. 6/2017
Trainee: Job Title:
Company: Contract#: Employer ID #:
Contact Name: Phone #: Email:
Address:
City: State: Zipcode:
Section 1: Contact Information
Complete the contact information for the OJT Provider and the Employer.
OJT Provider: Buffalo and Erie County Workforce Development Consortium, Inc.
Contact Person:
OJT Address:
Telephone #:
Email:
Fax #
Employer Name:
Account # or FEIN:
Employer Address:
Contact Person:
Telephone #:
Email:
Fax:
Section 2: Current Training Data Complete the blanks with information about the trainee’s data.
Trainee Name:
Trainee Social Security Number
Trainee Job Title
O*NET Soc #:
Hourly Wage:
Reimbursement Rate:
Maximum Training Hours: Maximum Reimbursement:
FOR OFFICE USE ONLY
ADDENDUM F – OJT CONTRACT MODIFICATION
Rev. 6/2017
Section 3: Modification Description Complete this section with specific details that modify changes to the contract.
This Modification incorporates the following changes:
Section 4: Signatures I hereby agree to the changes set forth in this modification. All other terms and conditions remain in full force and
effect.
Authorized Signatures:
[Company’s Name] Buffalo and Erie County Workforce
Development Consortium, Inc.
By: By:
SIGNATURE SIGNATURE
PRINT NAME PRINT NAME
TITLE: TITLE
DATE DATE
On this day of , 20__ before me the subscriber, personally appeared to me known, who being by me
duly sworn, did depose and say that he (she) resides in , New York; that he is the of the
corporation described herein and which executed the foregoing instrument that he (she) is the representative of the
corporation described in and who executed the foregoing instrument, and he(she) duly acknowledges to me the execution
of the same.
STATE OF NEW YORK
COUNTY OF ERIE SS.:
CITY OF BUFFALO
ADDENDUM G – OJT EMPLOYER MONITORING REPORT
Rev. 6/2017
Trainee: Job Title:
Company: Contract#: Employer ID #:
Contact Name: Phone #: Email:
Address:
City: State: Zipcode:
Trainee Information
1. Is the participant receiving the same fringe benefits as other employees? Yes No
2. Is the training outline being followed? Yes No
3. Are the necessary equipment, tools, & supervision available? Yes No
4. Have prior monitoring reports & corrective action plans (if any) been addressed? Yes No
5. Are there any new constraints affecting the company that could prevent the OJT contract
from reaching its scheduled conclusion? Comments:
Yes No
6. Has there been any attendance, punctuality, or disciplinary problems? Comments:
Yes No
7. Is the OJT trainee making adequate progress towards training goals? Comments:
Yes No
8. Are there any other issues or concerns? Comments:
Yes No
9. Describe any corrective actions you have or will implement to address above mentioned issues/concerns?
Yes No
10. Is the Employer satisfied with the services provided by the OJT program? Yes No
11. Does the Employer have any recommendations for improvement to the program?
(Please complete on backside of report)
Yes No
Business Applicant Signature
COMPANY REPRESENTATIVE DATE
MONITOR DATE
FOR OFFICE USE ONLY
ADDENDUM H – OJT TRAINEE MONITORING REPORT
Rev. 6/2017
Trainee: Job Title:
Company: Contract#: Employer ID #:
Contact Name: Phone #: Email:
Address:
City: State: Zip:
Trainee Information 1. Did you receive a company orientation and explanation of the OJT program? Yes No
2. Are you receiving the same fringe benefits as other employees? Yes No
3. Is necessary equipment, tools & supervision available to do your job? Yes No
4. Do you have a copy of your training plan and is it being followed? Yes No
5. Do you sign and keep time records? Yes No
6. Does the worksite and working conditions appear safe and sanitary? Yes No
7. Are you aware of the internal grievance procedure? Yes No
8. Have you had to use the procedure? Yes No
9. If yes, what was the result?
10. What was your hourly wage when you started? $_____ Now $______
11. How many hours per week are you working? _______
12. Describe your duties :
13. Does the participant have any recommendations for improvement to the program?
Authorized Signatures
TRAINEE SIGNATURE DATE
MONITOR SIGNATURE DATE
FOR OFFICE USE ONLY
Rev. 6/2017
ADDENDUM I ‐ OJT TRAINING FUNDING OPTIONS
Workforce Innovation and Opportunity Act (WIOA)
WIOA OJT National Emergency Grants (NEG)
Trade Adjustment Assistance (TAA)
Training Eligibility Adults Dislocated Workers Older Youth
NEG‐OJT funds may be available through the NYSDOL for long‐term Dislocated Workers. For current funding availability and eligibility requirements, contact the WDC Business Services Specialist or OJT‐[email protected]
Trade‐affected workers who have been determined as entitled for TAA by NYSDOL.
Wage Reimbursement Rates for Businesses
WIOA provides for reimbursement of up to 50% of the wage rate of the participant.
Wage reimbursement is based on number of employees of a business. For eligible reimbursement rates, contact the WDC Business Services Specialist or OJT‐[email protected]
Reimbursement may not average more than 50% of the wages paid by the business to such trainee during the training period.
Reimbursement Caps No reimbursement limit imposed under federal statue or regulations. Local policy may establish caps.
Wage reimbursement cannot be calculated at a wage higher than the current average wage rate for the state. Contact OJT‐[email protected] for the current wage rate.
OJT programs up to 52 weeks are capped at $10,000. Programs in excess of 52 weeks and up to 104 weeks are capped at $20,000.
Duration of Training No duration limit specified under Federal statue/regulation. Local policy may impose limits.
USDOL/ETA sets the limits on OJT‐NEG funding (often a 6‐month period). See the WDC Business Services Specialist for more information.
OJT is limited to 104 weeks
Special Conditions May be developed with private for‐profit and not‐for‐profit businesses, but not with public sector entities
OJT cannot be approved for Adversely Affected Incumbent Workers.
Rev. 6/2017
Attachment B 1 11-04-10
OJT Due Diligence Request Form
Please submit this information via e-mail to [email protected]. List your
NYSDOL Regional Business Services Associate Representative in the cc line of your submission.
Local Area/Contact Information Date of request:
Click here to enter LWIA and contact information. Click here to enter date.
Requesting Staff Person’s Name
Click here to enter the requesting staff person’s name.
Business Name: Business FEIN:
Click here to enter full business name (including DBA). Click here to enter FEIN.
Business Address:
Click here to enter address.
Business Contact Information
Click here to enter name, phone number and e-mail address.
Industry/Type of Business:
Click here to enter description of the industry/type of the business.
Reason for Due Diligence Check:
Local OJT
TAA
Other
Click here to enter the reason for Due Diligence (i.e. OJT/NEG, State-level OJT, etc).
1
INFORMATION AND COMPLAINTS INVOLVING FRAUD, ABUSE, OR OTHER CRIMINAL ACTIVITY
MUST BE REPORTED DIRECTLY AND IMMEDIATELY TO:
Secretary of Labor
U.S. Department of Labor Washington , DC 20210 and State Representative
New York State Department
of Labor 290 Main Street
Buffalo, NY 14202
Grievance Summary
The Workforce Innovation and Opportunity Act (WIOA) Section 683.600 requires that each administrative entity ,
contractor, and grantee under this Act shall establish and maintain a grievance procedure for grievances or
complaints about its programs and activities from participants, subgrantees, subcontractors , and other interested
persons.
The Buffalo and Erie County Workforce Development Consortium , Inc. (WDC), acting as administrative
entity and grant recipient for the Buffalo and Erie County Workforce Investment Board, has established
and maintains the following procedures for filing grievances .
TYPES OF GRIEVANCES
There are three (2) types of grievances , which are briefly described below: Non-criminal complaints: alleging violations of the WIOA rules and regulations, a WIOA grant and/or a WIOA
agreement; and
Criminal Complaints: alleging fraud, abuse, and other criminal activities .
FILING A GRIEVANCE
Non- Criminal Complaints
Complainants should attempt to resolve non-criminal complaints at the lowest level (i.e. Program Operator,
employer , immediate supervisor, etc.) prior to filing a complaint with the Complaint Resolution Officer
(CRO), Lavon Stephens, 726 Exchange Street, Suite 630, Buffalo, New York 14210, 716-819-9845 has
been designated CRO for non- criminal complaints. Non-criminal complaints must be filed within one (1)
year of the alleged occurrence, but should be filed as soon as possible. If unable to resolve the complaint at
lower levels, the Complainant should submit his/her complaint in writing to the CRO who will provide written
notice to the Complainant informing him/her of the date, time, and place of the hearing. Upon receipt, the CRO
shall conduct an investigation within ten (10) business days and will meet with complainant and respondent
within fifteen (15) business days from which the complaint was filed to attempt to reach an informal resolution.
Should this not be achieved, the Complainant may request a formal hearing which shall take place no later
than thirty (30) business days from the filing of the complaint. Within ten (10) days of formal hearing, a written
determination on the resolution of the complaint shall be issued and shall be communicated to the parties
within thirty (30) calendar days of the hearing.
The complainant or respondent may request a review of the complaint by the Governor within ten (10) days of
receipt of an unsatisfactory decision or if CRO has failed to issue a decision within sixty (60) business days of the
filing of the complaint. The request for review at the State level must be submitted in writing to the WIOA Hearing
Officer, NYS Department of Labor, State Office Campus, Building 12, Room 168, Albany, New York 12240. A copy
of the request should also be sent to State Representative, NYSDOL, Workforce Development and Training Division,
290 Main Street, Buffalo, New York 14202. The Governor shall issue a decision within thirty (30) days of receiving
the request. Should no decision be rendered, the Complainant or Respondent may elevate the complaint to the
Secretary of the US Department of Labor, 200 Constitution Avenue NW, Room N-4123, Washington , DC 20210.
Criminal Complaints
Criminal complaints will be reported directly to the US Secretary of Labor (see address above) . Individuals
wishing to report fraud or abuse may contact the Office of the Inspector General at 1-800-424-5409 .This
number is to be used ONLY for allegations of fraud or abuse.
CERTIFICATION : My signature indicates that the Discrimination Complaint and Grievance Procedures as appear
on this sheet have been provided to me and reviewed with me.
Signature _ Date _
Department of Labor W. Averell Harriman State Office Campus Building 12, Room 440, Albany, NY 12240 www.labor.ny.gov
New York State
Workforce Development System
Technical Advisory #09-17.1
February 4, 2015
To: Workforce Development Community
Subject: Individual Employment Plans/Training Plans for WIA Participants in Training
Purpose
To establish New York State policy that an Individual Employment Plan/Training Plan
(IEP/TP) must be created for every customer entering training, provide guidance on the
use of IEPs/TPs to justify and plan training and outline minimum criteria for an IEP/TP.
This TA rescinds and replaces TA#09-17, dated October 2, 2009.
Policy
An IEP/TP must be created for every WIA participant as a justification for training. The
attached sample form can be used as the IEP/TP. This form may be used as is, or it
may serve as a guide for a local area to develop their own IEP/TP format. If a local
area wishes to design its own form, it must incorporate the following minimum criteria:
1. The customer’s occupational goal;
2. The labor market outlook for the customer’s goal;
3. Summary of the customer’s existing skills, which may include transferable and occupational skills, including those gained from hobbies or volunteer work. Customer interests, work values and aptitudes should be highlighted as appropriate to the employment goal identified;
4. Summary of customer’s skills gaps, remedial education, and supportive service needs;
5. The justification for the particular training program or provider; and
6. The action plan including but not limited to: referrals to training and supportive services (including needs-related payments) as well as the start and anticipated completion dates for each action step identified.
2 02/05/2015
Additional information may be added as desired. Local areas may want to encourage
customers to complete the IEP/TP with staff to demonstrate that they have synthesized
their assessment, career guidance and labor market information. A signed IEP/TP, such
as the one attached, should be provided to the customer to serve as a reminder of their
status and need for training.
Background
Guidance on initial assessment can be found in TA #08-4.2
An IEP/TP serves as a record of the justification for training, as well as making the
justification explicit.
Note that the TAA Employment Plan provided in TA #04-06 meets the criteria outlined
for an IEP/TP described in this TA, therefore, TAA training applicants using the TAA
employment plan will not need a separate IEP/TP completed.
Additionally, participants enrolled under Section 599 will not require a separate IEP/TP
since the application for the 599 program requires information equivalent to what
NYSDOL is requiring for an IEP/TP.
Attachments
A. Sample Training Justification and Action Plan
The New York State Department of Labor is an Equal Opportunity Employer. If requested, program auxiliary aids and services are supplied to individuals with disabilities
Career Center Supplemental Questionnaire Additional Information & Program Eligibility
Name: NYID#: Please answer these questions to help us determine if you qualify for other Workforce System programs and services. This information is confidential and will only be used to determine further program eligibility, federal reporting requirements for Workforce Innovation and Opportunity Act-funded programs, and affirmative action requirements. We would like you to complete this form so we can help you better. However, answers are voluntary.
1. Are you or any member of your family receiving any Public Assistance/Low Income? Yes No
Check all that apply: TANF (Temporary Assistance for Needy
Families) Issued Date ____/_____/_____
Food Stamps/SNAP Issued Date ____/_____/_____
GA (General Assistance State/Local) Issued Date ____/_____/_____
RCA (Refugee Cash Assistance) Issued Date ____/_____/_____
Safety Net/Home Relief Issued Date ____/_____/_____
SSI (Supplemental Security Income) Issued Date ____/_____/_____
SSDI (Social Security Disability Insurance) Issued Date ____/_____/_____
Exhausting TANF within two years Issued Date ____/_____/_____
Low income individual with a total family income that does not exceed the higher of:
The poverty line OR 70% of the lower living standard income level Other
2. Are you a person with a disability? Yes No Prefer not to answer Do you have a physical or mental impairment that substantially limits one or more of your major life activities? If Yes, do you have a:
Physical/Chronic Health Condition Physical/Mobility Impairment Mental or Psychiatric disability Vision-related disability Hearing-related disability Learning disability
Cognitive/Intellectual disability
3. Are you a Migrant or Seasonal Farm Worker? Yes No If “Yes,” check one of the following:
Seasonal Farm Worker: someone who is or was employed in the past 12 months in farm work of a seasonal or other temporary nature and who can return to their permanent place of residence in the same day. This does not include non-migrant individuals who are full-time students.
Migrant Farm Worker: a seasonal farm worker (see above) who travels to the job site and cannot return to their permanent place of residence in the same day. This does not include full-time students traveling in organized groups rather than with their families.
Migrant Food Processor: (see Migrant Farm Worker)
The New York State Department of Labor is an Equal Opportunity Employer. If requested, program auxiliary aids and services are supplied to individuals with disabilities
ES102 (06/17)
4. Are you a spouse of a US Armed forces member on active duty and lost your job as a direct result of relocation due to a permanent change your spouse’s duty station? Yes No
5. Are you a Displaced Homemaker? Yes No Have you been providing unpaid services to family members in the home and: • Depended on the income of another family member but are no longer supported by that income; or are
the dependent spouse of a member of the military on active duty and whose family income is significantly reduced due to a deployment, a call or order to active duty, or the death or disability of the member, AND
• Are unemployed or underemployed and are having trouble finding or keeping employment.
6. Are you a single parent? Yes No Are you a single, separated, divorced or widowed person who has primary responsibility for one or more dependent children under age 18 (including single pregnant women)?
7. Are you homeless? Yes No Do you lack a permanent and suitable nighttime residence? This includes: • Sharing housing with other persons due to loss of housing, economic hardship or a similar reason, • Living in a motel, hotel, trailer park or campground due to a lack of other suitable options, • Living in an emergency or temporary shelter, • Abandoned in a hospital, • Awaiting foster care placement, or • Having a main nighttime residence that is a public or private place such as a car, park, abandoned
building, bus or train station, airport or campground.
8. Are you an ex-offender? Yes No Were you subject to any stage of the criminal justice process? Do you need help overcoming barriers to employment resulting from a record of arrest or conviction for crimes against persons or property, status offenses or other crimes?
9. Are you an English Language Learner? Yes No Do you have limited ability in speaking, reading, writing or understanding English? Do you meet one of the following two conditions? • Is your native language a language other than English? • Do you live in a family or community where a language other than English is the main language?
10. Do you think you have a cultural barrier? Yes No Do you have attitudes, beliefs, customs or practices that may make it hard for you to find work?
11. Do you lack basic skills? Yes No Are you unable to solve problems, or read, write, or speak English at a level necessary to function on the job, in your family, or in society?
I certify that the information given on this document is true and accurate to the best of my knowledge. Signature Date
USCIS Form I-9
OMB No. 1615-0047 Expires 08/31/2019
Employment Eligibility Verification Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 07/17/17 N Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)
Address (Street Number and Name) Apt. Number City or Town State ZIP Code
Date of Birth (mm/dd/yyyy) U.S. Social Security Number
- -
Employee's E-mail Address Employee's Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until (See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1 Do Not Write In This Space
Signature of Employee Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)
Last Name (Family Name) First Name (Given Name)
Address (Street Number and Name) City or Town State ZIP Code
Employer Completes Next Page
Form I-9 07/17/17 N Page 2 of 3
USCIS Form I-9
OMB No. 1615-0047 Expires 08/31/2019
Employment Eligibility Verification Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1
Citizenship/Immigration Status
List AIdentity and Employment Authorization Identity Employment Authorization
OR List B AND List C
Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)
Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial
B. Date of Rehire (if applicable)Date (mm/dd/yyyy)
Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative
LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED
Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
4. Employment Authorization Document that contains a photograph (Form I-766)
5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:
Documents that Establish Both Identity and
Employment Authorization
6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;
and(2) An endorsement of the alien's
nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are unable to present a document
listed above:
1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
9. Driver's license issued by a Canadian government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish Identity
LIST B
OR AND
LIST C
7. Employment authorization document issued by the Department of Homeland Security
1. A Social Security Account Number card, unless the card includes one of the following restrictions:
2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)
3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
4. Native American tribal document
6. Identification Card for Use of Resident Citizen in the United States (Form I-179)
Documents that Establish Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3Form I-9 07/17/17 N
Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
Dislocated Worker Definitions
Reference WIOA Section 133 (b)(2)(B) as a person who
Category 1 – DW
• Has been terminated or laid off, or who has received a notice of termination or layoff, from employment; and
• Is eligible for or has exhausted entitlement to unemployment compensation; or has been employed for a
duration sufficient to demonstrate, to the appropriate entity at a one-stop center referred to in section 121(e),
attachment to the workforce, but is not eligible for unemployment compensation due to insufficient earnings or
having performed services for an employer that were not covered under a State unemployment compensation law; and
• Is unlikely to return to a previous industry or occupation. Evidence to support this can include Career Center
staff assessment based on LMI, profiling score of 50 or higher, customer has exhausted UI
Category 2 – DW mass layoff or closure
• Has been terminated or laid off, or has received a notice of termination or layoff, from employment as a result
of any permanent closure of, or any substantial layoff at, a plant, facility, or enterprise;
• Is employed at a facility at which the employer has made a general announcement that such facility will close
within 180 days; or
• For purposes of eligibility to receive services other than training services described in WIOA section 134(c)(3),
career services described in section 134(c)(2)(A), or supportive services, is employed at a facility at which the
employer has made a general announcement that such facility will close.
Category 3 – DW self-employed
An individual who was self-employed (including employment as a farmer, a rancher, or a fisherman) but is unemployed
as a result of general economic conditions in the community in which the individual resides or because of natural
disasters.
Category 4 – DW displaced homemaker
An individual who has been providing unpaid services to family members in the home and who—
• Has been dependent on the income of another family member but is no longer supported by that income; or (ii)
is the dependent spouse of a member of the Armed forces on active duty (as defined in section 101(d)(1) of title
10, United States code) and whose family income is significantly reduced because of a deployment, a call or
order to active duty pursuant to a provision of law, death or disability of the member and
• Is unemployed or underemployed and is experiencing difficulty in obtaining or upgrading employment.
Category 5 – DW dislocated due to foreign trade
Job lost due to the impact of foreign trade and the phenomenon commonly known as "off shoring” and is part of a
worker group covered under a certified trade petition. TAA certified customer.
Category 6 – DW spouse of a member of the Armed Forces
• An individual who is a spouse of a member of the Armed Forces on active duty (as defined in section 101 (d)(1)
of the title 10, United States Code), and who has experienced a loss of employment as a direct result of
relocation to accommodate a permanent change in duty station of such member; or
• (ii) is the spouse of a member of the Armed Forces on active duty and who meets the criteria described in WIOA
Section 3 (16)(B). (Category DW-1)
Dislocated Worker OSOS Checklist
Completing an Employability Profile � Update Customer Assignment section (general info tab) � Employment Status (general info tab) � Date of birth (general info tab) & DOB tab for validation – See below � Gender (general info tab, should be recorded when training is funded) � Education information (general info tab, and Ed/Lic tab- Schools) - School Section must have at least one complete entry for customers who possess an Associate’s Degree or more (i.e. Bachelor, Master or Doctorate). This information must match the Education Information on the General Info Tab. � Objective (objective tab) � O*Net Title (objective tab & work history tab. At least one O*Net title from the objective tab must match the O*Net title listed in work history tab) � Skills (skills tab) � Work History (work history tab) � Replace “TCC Update” or “TO BE UPDATED”, � Start and End dates, (unless still employed) � Reason for Leaving � ONET Title � Job Duties � Wage � Eliminate any duplicated work histories
Dislocated Worker Status must select one under Reason for Leaving- Work History Section
� Category 1-DW – Laid off; Unlikely to Return to Previous Occupation � Enter the customers qualifying dislocation date, tenure and O*Net title � Category 2- DW mass layoff or closure � Enter the customers qualifying dislocation date, tenure and O*Net title � Category 3- DW self-employed � Enter the customers qualifying dislocation date, tenure and O*Net title � Category 4-DW displaced homemaker
• Job title = Homemaker, with the participant’s address and name as employer. • No start or end date is required. Use 0.01 as the wage.
� Category 5-DW Military Spouse (Select category 1-DW until OSOS is updated) � Enter comment, “Customer is a Dislocated Worker-Spouse of a member of the Armed Forces” � Category 6- Dislocated worker due to foreign trade � Enter the required information in the TAA/NAFRA-TAA field. This information can be found on the Customer’s TA 722 eligibility form.
Date of Birth Validation � Validate DOB (DOB tab) � UI customers will be completed automatically
All customers who receive funding for training will also need an Individual Employment Plan (IEP) completed. An IEP should include all of the listed information.
Individual Employment Plan (IEP) Checklist � Identify the customer’s occupational goal � Look up labor market outlook for the customer’s goal � Summarize the customer’s existing skills, which may include transferable and occupational skills, including those gained from hobbies or volunteer work. Customer interests, work values and aptitudes should be highlighted as appropriate to the employment goal identified � Summarize the customer’s skills gaps, remedial education, and supportive service needs � Justification for the particular training program or provider � Create an action plan including but not limited to: referrals to training and supportive services
� Non UI – use DMV verification with Driver’s/non Driver’s license or source document- If no DMV ID, use other acceptable documents such as passport or birth certificate.
Selective Service (for males 18-24 years of age/born after 1959) � Check Selective Service box (add’l info tab) � Enter registration number – Note that if there is no registration, customer can’t be served with WIOA funds, only Wagner/Peyser. If customer is past the age of registration (over 25), then the customer must self-attest in writing that the failure to register was not knowing and willful.
Demographic Characteristic/Barriers to Employment Disability (add’l info tab) � Enter Disability Status (Disabled/Not Disabled or Not Disclosed) � Enter Disability Category for Disabled customers Low Income - Public Assistance (add’l info tab or prgms/pa tab) � Check Poverty guidelines (http://labor.ny.gov/workforcenypartners/tools.shtm �Enter income status (add’l info tab) – Income 70% LLSIL box If neither eligibility are met record “NA” � Enter ‘Yes’ for any public assistance and include a date (prgms/pa tab) English Language Learner-LEP (Comp Assess window, Education tab) � Select “yes” for Limited English or “no” � Add comment, LEP per customer attestation dated (mo/day/year), � Add primary language and needs in the Primary Language tab Cultural Barriers � Enter comment; the comment must include customer’s cultural barriers. Single Parent (Comp Assess window, Family tab) � Record the selection that corresponds to the information provided. If no information provided, choose “not reported”. Homeless (Comp Assess window, Housing tab) � Record ‘Homeless’ in the current housing field or if not homeless under Housing Assistance- “None” Offender (Comp Asses window, Legal tab) �Select ‘Yes’ or “Not Applicable” in the offender Status field
(including needs-related payments) as well as the start and anticipated completion dates for each action step identified. Then add an IEP activity to the customer record. **RESEA Customers** - OSOS activities should follow the RESEA Guide
Required OSOS Activities for Dislocated Workers going to training � Initial Assessment: Assessment interview, Initial Assessment [LX Enrolling] � Initial Assessment Outcome: CDS � Individual Employment Plan � Workforce Information Services Staff assisted (LMI) � Career Guidance- intensive
Buffalo and Erie County Workforce Development Consortium JOB ORDER FORM 726 Exchange Street Suite 630 Buffalo, New York 14210 Resumes to: (716) 819-9845 FAX (716) 819-9849 The information you provide on this form will help us understand your hiring needs and will assist us in locating the most suitable candidates for you.
Please fill out one Job Order Form for each job title and then mail, fax or call the office listed above to place your order.
EMPLOYER INFORMATION
Date of Posting: Date Posting Expires: Unemployment Registration No./Federal I.D.
#
Business Name:
Street Address: City: State: ZIP:
Mailing Address: City: State: ZIP:
Telephone: FAX: e-mail:
Company Contact Person:
Title:
Would you like your company name made available to the public on your job listing?
Yes No Referral Method: (select all that apply):
FAX Mail e-mail URL
JOB INFORMATION
Title: O*Net Code # Worksite location:
Number of job openings:
Duration: regular temp. temp. to perm. seasonal
If this job is temporary, how long do you expect it to last?
This job is: Full Time Part Time # Hrs
Work days per week: (check all that apply)
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Shift: First Second Third Varies Other Explain:
Education required: Special Licenses/Certificates/Degrees:
Experience: Years: Months:
Would you accept a trainee?
Yes No
Is public transportation available?
Yes No
Is a car needed to do the job?
Yes
No
Wage: Minimum Pay $ To Maximum Pay $ Per hour week month annum
Is any of this pay based on draw or commission at any time during employment? Yes No
Driver’s License Required? Yes No Class: Union Affiliation required? Yes No
Benefits: (check all that apply)
Health Insurance Paid Holidays
Dental Insurance
Vision Insurance Retirement/401k
Paid Vacation Life Insurance
Paid Personal Leave Clothing Allowance
Paid Sick Leave ST/LT Disability
Tuition Reimbursement
Other hiring requirements: (check all that apply)
Criminal Background or Child Abuse Registry Check
Reference Check Credit Check
Driving Record Check
Medical Exam Drug Screenings
Fingerprinting
Own Tools Own Car
Job Description: Brief explanation of job duties (Attach company job description if available)
Four major skills needed to perform job (in priority order)
1. 3.
2. 4.
Your business may be eligible for tax incentives and/or on-the-job training wage subsidies if you hire from target groups. Would you like more information on this subject? Yes No
23 revised 10/01/10