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Workforce Connections General Policies ADW-030-05 Record Retention Pro1rram Participant File

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Policy Approved By: WC Executive Director ( \ . l -

Policy Adopted on: August 01, 2013 'J

Purpose: ~ To establish Workforce Connections' (WC) Policy regarcli 1g the Adult and Dislocated Worker Program: Record Retention Requirements

Background: By law, all Local Workforce Investment Areas and sub-recipients are required to maintain and retain records of all programmatic and fiscal activities funded under the Workforce Investment Act of 1998 (WIA). Service Providers currently under contract with Workforce Connections and receiving WIA Title I formula funds shall follow this policy and must establish written procedures that meet the requirements of this policy.

Policy: Workforce Connections has established that for the purpose of Federal, State and local record retention requirements, all financial, statistical, property, applicant and program participant records and supporting documentation must be retain by Service Providers for a period of at least three (3) years subsequent to the date of submission of final grant expenditure report, close-out package of the date all audits are complete and finding/ all claims have been resolved, whichever occurs first. This policy applies to all Workforce Connections Service Providers providing WIA Title I services to Adult and Dislocated workers.

Reference: [PL 105-220 Sec.136 (f) (3)][29 CFR §95.53][29 CFR §97.42][29 CFR §97.20 (b) (6)] [WIA State Compliance Policy 5.4][WC Policy 5.6]

A. Required Workforce Connections' Service Providers and/or contractors must establish and maintain adequate accounting books, and record control systems to accurately and timely track and report all financial transactions related to work performed and costs incurred relative to WIA Title I funded activities.

B. All information required by Federal, State, and local reporting requirements must be collected for each individual receiving service under a WIA Title I funded program. The appropriateness of any service provided to an eligible program participant must be documented timely and accurately in WC MIS-NVTRAC and support documentation must be kept in program participant files for monitoring and data validation purposes. WIA participant files must be stored, at all times, in an area that is physically safe from access by unauthorized persons and participant data will be processed electronically using WC MIS-NVTRAC system of record.

I Workforce Connections Policy ADW-030-os I I Adult & Dislocated Worker Program

Workforce Connections is an egual opportunity empl.oycr / program.

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Addendum-1 I. General Provisions

A. Limitation of Public Access to Records

1. Personal records ofWIA Title I program participants must be kept private and confidential at all times in compliance with Federal, State and local requirements, and will not be disclosed to the public. Personal information may be made available to One-Stop partners or Service Providers on a selective basis consistent with the WIA program participants' signed release of information form. In addition, this information may be made available to persons or entities having responsibilities under WIA Title I including representative of:

a) The Department of Labor b) The governor c) State Workforce Investment Support Services Division d) Local WIA Title I recipients (WC's Service Provider(s)) e) Local WIA Title I sub-recipients (WC's Service Provider(s)) f) Appropriate governmental authorities involved in the administration of WIA

Title I to the extent necessary for its proper administration

II. Prior collection of WIA program participants' personal information

A. All individuals must be notified that such information will only be used for the purposes of services under the WIA Title I funded program.

B. All individuals shall also be notified that with written consent, such information may be shared with other Workforce Connections network partner organizations for the purpose of referral and potential coordination of services beyond WIA Title I services.

C. All individuals must be provided with initial and continuing notice concerning Equal Opportunity and Nondiscrimination Regulations, which prohibits discrimination against all individuals in the United States on the basis of their race, color, religion, sex, national origin, age, disability, political affiliation, or belief, [WIA Sec. 188; 29 CFR part 37; and 20 CFR § 667.600]. Service Providers must take appropriate steps to ensure that communications with individuals with disabilities are as effective as communication with others.

D. In accordance with Section 7 of the Privacy Act of 1974 [§ 552a (note)], disclosure of social security number, unless the disclosure is required by Federal statute, it shall be unlawful for any Federal, State or local government agency to deny to any individual any right, benefit, or privilege provided by law of such individual's refusal to disclose his social security account number.


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Addendum-1 Continuation

1. Disclosure of an individual's social security number pursuant to the Internal Revenue Code, where it is used as the identifying number for the purposes of a return, statement or any other document under the Code (e.g., for payment of wages for OJT program, Work Experience, etc.) may be properly requested.

2. It is important for service providers to request the applicant's social security number at the time of the Individual Employment Plan development and advise them that their social security numbers are kept in a secure and confidential manner. Applicants shall also be advised that the State only uses the social security number for the following:

a) Tracking Unemployment Insurance wage records for the calculation of program performance measures outcomes; and

b) Wages paid while participating in a WIA Title I funded activity (e.g., OJT, WEX, etc).

Note: 1. Not obtaining a Social Security Number from a program participant means that any outcomes for this participant would be excluded from performance measures unless supplemental information is available to verify the performance outcomes for non-wage based measures.

III. Confidentiality and Security of Program Participant Information

A. The Workforce Investment Act (WIA) requires that all applicant and program participant personal information is and remains confidential. Appropriate efforts must be taken to protect the confidentiality of personal information that is attributable to any specific individual (e.g., address, social security number, telephone number, etc.). It is the policy of Workforce Connections to ensure that program participant personal information is collected, used, and stored in a manner that will not be accessible to unauthorized personnel. Personal information is not to be collected unless it is needed for the provision of a Workforce Investment Act service or to determine eligibility for a specific Workforce Investment Act program, and that is not used for any purpose other than the program or service for which it was collected unless the applicant or program participant, (if the individual is an adult), or a parent or legal guardian of the applicant of program participant, (if the individual is a minor or dependant), gives specific written consent for the information to be shared. The applicant or program participant may receive a copy of any information collected from them at their request.

Note: 2. Workforce Connections is committed to protecting the confidentiality of all Workforce Investment Act applicants and program participants utilizing the Workforce Connections designated One-Stop center, and any program/services for adults, dislocated workers or youth funded program by Workforce Connections.


Workforce Connections is an equal opportunity employer/ program.

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Action: Upon acknowledgement of this policy it is the Service Providers' responsibility to ensure and observe all staff are informed of this policy, to create an internal process to ensure accountability, and procure signed Confidentiality Agreement from all Workforce Investment Act program staff.

IV. General Requirements

A. Service Providers and/or contractors must request and often collect personal information to determine eligibility for WIA Title I programs, but to also be able to recommend and refer program participants to partner agencies and other community organizations. Such information collection shall occur as confidential as possible and should not required open discussion in a public space.

B. Program Participants should have the option of providing required information in written form, which cannot be shared or left unattended by any member of the Workforce System, nor shared without the specific written approval of the program participant with any other program or Service Providers not specifically authorized to view such information under the provision of the Workforce Investment Act.

C. Service Providers and/ or contractors must collect and store program participants' files and records in secured, locked file cabinets, locked file areas, or desks that do not permit unauthorized users/personal access. Any document or data collected in error, or that must be destroyed, must be shredded.

D. The identity of any individual who furnishes information relating to an investigation, compliance review, or customer satisfaction survey, including the identity of any individual who files a complaint, must be kept confidential and consistent with a fair determination of the issue.

E. As written in WC - Policy ADW-030-04 Data Recording and Management item I(C)(t), data security involves ensuring only authorized staffs have access to electronic databases and paper files containing sensitive program participants' information. It is imperative that program participants' information is protected at all times. Program participants' information can only be released to third party agencies, or entities if the program participant has authorized such release, or the custodian of the records is presented with a valid court order requesting information pursuant to legal action.


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V. Program Participant Files - Forms Chart

WIA-ADW

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Section IV Related Needs

1. Supportive Services Log

2. SS support documents

Section I Eligibility

1. Cover Page or Check List

2. NVTRAC - EDR

3. Nevada State residence

4.SSN

5.SSR

6. I-9 form

7. E.O is the law

8. Rights and Responsibilities

9. WIA required forms -Table A

SectionV Training Activities

Section II Career

Objective Goals 1. IEP

2. Assessments

Section Ill Progress

1. NVTRAC - PPR

2. NVTRAC -Case Notes

3.Follow-Up

I

1. Individual Training Authorization

2. o.rr contract

3. Attendance records

4. Timesheets

5. Copy of payments

6. Copy of invoices

7. CopyofSGA

8. Copy of Training plan

9. See WC Policies 3.03 and 3.07 for all required documents

Section VI Outcomes

1. Income Employment verification

2. Diplomas

3. Certificates

4. Credential



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VI. Program Participant Files - Support Documentation - Table A Section I - Elig!bility

ADULT AND DISLOCATED WORKERS General Eligibility Criteria

(Verify each criterion unless specified otherwise)

Birth Date / Age Note: Applicants must be 18 years or older at the time of registration to participate in this program.

U.S. Work Authorization Note: For Changes to the list of acceptable identity and work authorization documents, go to : www.uscis.gov or www.uscis.gov/i-9Central

Selective Service Registrant Note: Each male registrant 18 years of age or older born on or after January 1, 1960, must present evidence that he has complied with Sec. 3 of the Military Selective Service Act. Each male who turns 18 years of age during WIA program participation must also submit evidence that he has complied with the requirements of the Military Selective Service Act.

Acceptable Support Documentation (Only one document per eligibili!)' criterion is required)

D Baptismal or church record D Birth Certificate D DD-214 Form D Driver's License D Federal, State or Local Government Issued Identification

Card D Hospital Record of Birth D Passport D Public Assistance / Social Service Record Cl School Record D Telephone Verification D Work Permit

D Verification Document(s) that satisfy List A of the I-9 form 03-08-2013 N OMB N. 1615-0047 Expires 03-31-2016

D Verification Document(s) that Satisfy List Band C of the I-9 form 03/08/2013 N OMB N. 1615-0047 Expires 03-31-2016

D Selective Service Acknowledgement Letter D Form DD-214 "report of separation" D Selective Service Registration Verification form, can be

found at: www.sss.gov D Selective Service Status Information Letter D Selective Service Registration Card D Selective Service Registration Record (form 3A) D Selective Service Verification form D Stamped Post Office Receipt of registration D Self Statement -TEGL 11-11Change1 and 2

WIA - Workforce Connections Required Forms D NVfRAC - Eligibility Determination Printout - Properly Signed and Dated1

D Equal Opportunity is the Law - Attachment A & A-1 D Release of Information Form - Attachment B D Participant Rights and Responsibilities - Attachment C D Nepotism Form - Attachment D D Dislocated Worker - Unlikely to Return Self-Statement - Attachment E (when applicable) D Participant Self-Statement - Attachment F D Telephone Verification Form - Attachment G D SSR Exemption form - Attachment H

1 Participant and program staff signatures must appear in this printout, no other form and/or signed paperwork is accepted.



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DISLOCATED WORKERS Eligibility Criteria Acceptable Support Documentation

(Verify each criterion unless specified otherwise) (Only one document per eli~bili~ criterion is reQufred) Elifilbility Group A - Terminated / Laid Off

1. (A) Has been terminated or laid off, or how has D Worker Adjustment and Retraining Notification Act. received a notice of termination or layoff, from (WARN) notice employment; AND D Photocopy of a printed media article or announcement

describing layoff. The photocopy must include the name of the source of publication and the date of publication

D Employer or union representative letter or statement D Potential applicant self-statement

(B) a) Is eligible for or has exhausted entitlement D Unemployment insurance records, including notice of

to unemployment compensation; OR unemployment insurance award (DE 429Z), and continued b) Has been employed for a duration award form (DE 2327)

sufficient to demonstrate attachment to the D Pay checks stubs workforce, but is not eligible for D W-2 and/ or Tax returns unemployment compensation due to D Unemployment insurance records, including DE 429Z insufficient earnings or having performed D Statement by Employer or union representative services for an employer that were not D Statement by an unemployment insurance representative covered under a State unemployment D Potential applicant self-statement compensation law; AND

D Appointment notice of referral to an initial assistance workshop (IAW); OR

(C) D Screen print of IAW schedule; OR

Is unlikely to return to a previous industry or D Reemployment plan generated from IAW; OR

occupation D Potential applicant self-statement D Labor market information that indicates lack of

industry/ occupation availability (printout) D Employment specialist determination / ES records

Elig!bili!)' Group B - Plant Closure / Substantial Layoff

Closure or substantial layoff: D Copy of a printed media article/announcement describing

the closure/mass layoff; the copy must include the name of the source and the date of publication

2. Has been terminated or laid off, or has received D Statement from the employer or union representative

a notice of termination or layoff, from employment D Copy of valid WARN notice provided by the employer or

as a result of any permanent closure of, or any authorized representative

substantial layoff at, a plant, facility, or enterprise; D Telephone verification

Note: In the case of downsizing or workforce D Potential applicant self-statement

reduction when it is unclear which employee will be Notice of Layoff or Laid-off: affected, a layoff notice is appropriate. D Copy of valid WARN notice provided by the employer or

authorized representative D Copy of other specific notice to employee of intent to lay-off D Employer of union representative letter or statement D Telephone verification

l:'i: D Potential aoolicant self-statement bO!



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DISLOCATED WORKERS (Continued) Eligibility Criteria Acceptable Support Documentation

(Verify each criterion unless specified otherwise) (Onl]' one document per eligibili!)!: criterion is required) Elig!bility Group B - Plant Closure / Substantial Layoff (Continued)

3. Is employed at a facility at which the employer has made a general announcement that such D Photocopy of a printed media article or announcement facility will close within 180 days; OR describing layoff. The photocopy must include the name of

the source of publication and the date of publication For the purpose of eligibility to receive core services D Employer or union representative letter or statement only, is employed at a facility at which the employer has made a general announcement that such facility will close.

Eligibili!)' Group C - Self-Employed 4. Was self-employed (including employment as a D Photocopy of a printed media article or announcement farmer, a rancher, or a fisherman) but is describing layoff. The photocopy must include the name of unemployed as a result of general economic the source of publication and the date of publication conditions in the community in which the D Copy of completed Federal Income Tax return, for the most individual resides or because of natural disasters. recent tax year

D Potential auulicant self-statement Elie:ibility Group D - Displaced Homemaker

D Potential applicant self-statement D Legal separation paperwork D Divorce decree D Public assistance record

5. Is a displaced homemaker D UI records D Copy of completed Federal Income Tax return, for the most

recent tax year D Death certificate of spouse D Wage earners layoff notice I UI award letter

Miscellaneous Criteria Eligibility Criteria Acceptable Support Documentation

(Verify each criterion unless specified otherwise) (Only one document per eligibility criterion is required) Unemployed D Potential Applicant self-statement [WIA Sec. 101 (47)] D Telephone verification

D Employment specialist or case manager determination Underemployed D Potential Applicant self-statement Applies only to displaced homemaker D Employment specialist or case manager determination

D Telephone verification

ADULT AND DISLOCATED WORKERS Eligibility Criteria Acceptable Support Documentation

(Verify each criterion unless specified otherwise) (Only one document per eligibility criterion is required) Social Security Number D Copy of Social Security Card Section 1(a) of this policy D Letter from the Social Security Administration showing SSN Item II(4)(a)(b) D CopyofW-2 form Note: 1. D DD-214 form 0

D Employment records D UI record , ,



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Section II - Career Objectives Goals


ADULT AND DISLOCATED WORKERS Intensive Services Required Support Documentation

(Ensure and verify proper completion)

WC - Policy ADW-030-03 Table B; C; and D 0 Fully executed Assessments 0 Properly signed and dated Individual Employment Plan 0 Must demonstrate participants' career/objective goals

0 Must show target dates for accomplishment

Section III-WC MIS-NVfRAC PPRLWC MIS-NVfRAC Case Notes report/Follow Up ADULT AND DISLOCATED WORKERS

Data Recording Required Support Documentation (Ensure and verify timely and accurate reporting)

WC - Policy ADW-030-04 Item II 0 Program Participation Report (properly signed) Data Requirements 0 Case notes report printout (at least once a month)

Section IV - Related Needs ADULT AND DISLOCATED WORKERS

Supportive Services Required Support Documentation (Ensure and verify justification for provision)

WC - Policy ADW-030-10 0 Properly completed supportive services log Supportive Services 0 Copy of properly signed and dated voucher(s)

0 Must be documented in IEP 0 Copy of record(s) related to payments 0 Case manager determination of need 0 Case noted justification

s ct" e I On V Tr . . A t" .• - amm2 c 1vitles ADULT AND DISLOCATED WORKERS

Services - Program Activities Required Support Documentation (Ensure and verify proper completion)

OJT 0 Fully executed pre-award check list - attachment A WC - Policy ADW-030-08 0 Fully executed skill gap analysis - attachment B

0 Fully executed training plan - attachment C 0 Fully executed OJT contract - attachment D 0 Must be linked participants' career/objective goals - IEP 0 Case manager determination of need 0 Case noted justification 0 List of additional required support documentation on WC -

Policy ADW-030-08 Item IV(B) ITA - Training 0 Fully executed Individual Training Authorization WC - Policy ADW-030-07 0 Properly completed IEP

0 Printout form WC ETPL 0 List of additional support documentation on WC - Policy

ADW-030-07 Item II



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Section VI - Outcomes

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ADULT AND DISLOCATED WORKERS


Performance and Outcomes Required Support Documentation

Progress - Achievements Cl Copy of certificate of completion Cl Copy of diploma Cl Copy of credential(s) Cl Income verifications Cl Follow up related paper work - retention

In order to ensure consistency among Service Providers and/or contractors, the above standard program participant file format is required. Standardizing the format also assist Service Providers and/or contractors to easily identify missing support documents and helps to ensure that auditors (internal or external) are able to find required documents and required support documentation in a more consistent and effective way.

Note: 3. Copies of all required records made by photocopying, or similar methods may be substituted for the original records always if they are preserved with integrity and are considered as admissible as evidence.

In the event and based on your project description and/ or scope of work requirements, a different format for program participant files is more suitable for your organization, Service Provider must submit proposed format to Workforce Connections for review and approval.

Action: Workforce Connections' Service Providers must maintain a formal file structure policy to include a data element validation checklist placed in the front of each WIA program participant file section for all program participants. Service Providers are responsible for ensuring that all data validation elements and supporting documentation are included in all participants' files.

General statutory requirements

1. If any litigation, claim or audit is started before the expiration of the three (3) years period, the records shall be retained until all litigation, claims, or audit findings involving the records have been resolved and final action taken, [29 CFR §95.53(b)(1)]; and [WIA State Compliance Policy 5-4].

2. The Federal grantor awarding agency, the Inspector General, the Comptroller General of the United States, or any of their duly authorized representatives, have the right of timely and unrestricted access to any books, documents, papers, or other records of recipients that are pertinent to the awards, in order to make audits, examinations, excerpts, transcripts and copies of such documents. This right also includes timely and reasonable access to a recipient's personnel for the purpose of interview and discussion related to such documents. The right of access in this paragraph are not limited to the required retention period, but shall last as long as records are retained, [29 CFR §95.53(e)]; and [WIA State Compliance Policy 5-4].

I Workforce Connections Policy ADW-030-os I Adult & Dislocated Worker Pro


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WC Attachment A Equal Opportunity is the Law

Applicable Program: -----------------

It is against the law for this recipient of Federal financial assistance to discriminate on the following bases: against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief; and against any beneficiary of programs financially assisted under Title I of the Workforce Investment Act of 1998 (WIA), on the basis of the beneficiary's citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIA Title I-financially assisted program or activity. The recipient must not discriminate in any of the following areas: deciding who will be admitted, or have access, to any WIA Title I-financially assisted program or activity; providing opportunities in, or treating any person with regard to, such a program or activity; or making employment decisions in the administration of, or in connection with, such a program or activity.

If you think that you have been subject to discrimination under a WIA Title-I financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either: The recipient's Equal Opportunity Officers [Donna Romo - State EO Officer, Mary Beth Hartleb-Southern Nevada WIB EO Officer, or the Director, Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue, NW, Room N-4123, Washington, DC 20210.

If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center (see address above). If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient). If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action.

I have read and understand my rights under federal law, and know that I have a right to file a complaint.

Applicant Signature and Date Witness Signature and Date

D Equal Employment Opportunity Employer/Program. D Auxiliary aids and services are available upon request to individuals with disabilities. D Donna Romo, State EO Officer (702) 486-6511 and (800) 326-6868 (TIY, Nevada Relay 711) D Mary Beth Hartleb, Southern NV Workforce Investment Board EO Officer (702) 638-8750 and (800)

326-6868 (TIY, Nevada Relay 711)


Workforce Connections i an equal opportunity employer/ program.

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WC Attachment B Release of Information

I, ___________________ , do hereby give Workforce Connections (Please print first and last name)

and its designee's permission to obtain and release information related to my employment and/or education.

Emplovment information to be obtained / released Education information to be obtained / released D Date of employment D Date of enrollment in training program D Job title D Date of diploma/certificate attainment D Wage rate D Type of diploma D Full time / part time status D Type of certification D Hours per week D Type of degree D Benefits received and reason for D Attendance records

termination (if applicable) D Progress

The authority for solicitation of your Social Security account number is from the Nevada Unemployment Insurance, section 15026.

By providing this number, these are the different ways it may be used by Workforce Connections and the State of Nevada:

D Studies and evaluations of the training and employment programs in which you may participate

D Getting information for future programs and budget planning D Checking for possible participation by you in other State or Federal program(s) D Studying long-term effects on all participants in this program D Finding ways to make this program more effective D Sharing information with other employment and training programs D Determination of employability

I allow release of this information for verification purposes. I do understand that Workforce Connections is an affiliate of the State of Nevada Department of Employment Training and Rehabilitation (DETR), and that the information provided is made available to the One Stop System partners to assist me with my training and employment goals and objectives.

My signature indicates that I have been informed and understand the ways my Social Security account number may be used by Workforce Connections or the State of Nevada.

Program Participant Signature Date

Witness Signature Date



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WC Attachment C Program Participant Rights and Responsibilities

Welcome and thank you for your interest in the Workforce Investment Act (WIA) -ADW Program! We sincerely hope that we are able to assist you with your employment needs. However, in order for us to provide you with the best services possible, there are certain procedures that we must share with you. Please read carefully each of the statements below. If you have any questions, do not hesitate to ask any of the WIA-ADW Program representatives for clarification or help.

Participant Rights

D To have all services and procedures explained to you in your native language whenever possible.

D To receive services without regard to race, national origin, sex, religion, language or political affiliation.

D To be treated fairly with courtesy and respect.

D To participate actively in the development of your self-sufficiency and Individual Employment Plan.

D To have all records kept confidential unless released by a signed consent form.

D To have access to information in your case file in accordance with established policy.

D To receive all appropriate services necessary to fulfill obligations under the self-sufficiency and Individual Employment Plan.

D To file a grievance in accordance with established policy in the event services are not rendered in a satisfactory manner.

I Workforce Connections Policy ADW-030-os I I

Participant Responsibilities

D Comply with all reporting requirements including giving notice within five (5) business days of any changes in your address, income, and employment status.

D Participate fully and appropriately in all required job search activities, orientations, assessments, job interviews, designed to help you secure employment.

D To report to your Case Manager and/or Workforce Developer if you are not able to participate in program-scheduled activities.

D Conduct yourself in a polite manner. D Accept any reasonable offer of

employment. D Sign all required forms.

Our mission is to help you find and keep employment that will allow hard-working, skilled individuals to support themselves and their families. Securing employment does not disqualify you from receiving additional services from this program. Do not hesitate to contact staff to report that you have found employment and they will continue to assist you with supportive employment services as needed. All cases are evaluated on an individual basis, always taking into consideration eligibility criteria.

Our WIA Program staff is committed to help you identify job leads and/or provide you with job opening referrals. It is also your responsibility to fully participate in job search activities on your own.

Adult & Dislocated Worker Program


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WIA-ADW Program is an employment / Training program. It is our responsibility to help you find employment, which will allow you to earn or attain self-sufficiency. In order for you to enroll in our program, you will be required to provide information to your Intake Coordinator during your first meeting. This meeting will give us the opportunity to establish all eligibility criteria and assess/determine what type of services will successfully lead you into employment. Looking for employment is a full-time job in and of itself, and we are fully committed to doing anything we can to help you in that endeavor. However, we expect that you will work just as diligently as we do.

Please remember that success is in your hands. We are here to support you and assist you with all employment-related needs. Also, remember that those who succeed are those who never give up. We are looking forward to establishing the best possible relationship. Please work together with us in achieving your employment expectations.

I understand that by signing my name, I am agreeing to comply with the Individual Employment Plan developed today. I understand that the Workforce Investment Act -Adult and Dislocated Workers Program is agreeing to help me to secure employment as quickly as possible, and will provide supportive services to assist me with this goal, as long as I am in compliance with the plan developed today.

I understand that I may request changes in the Individual Employment Plan by contacting my Case Manager or Workforce Developer.

I Workforce Connections Policy ADW-030-os I I

I understand that assistance and services are directly related to daily plan compliance.

I also indicate by signing below that I have been informed that the Workforce Investment Act Title I - Adult and Dislocated Workers Program is an Equal Opportunity Employment program, and that auxiliary aids and services are available upon request to individual(s) with disabilities.

If you require assistance or have concerns, program staff is available to provide information and referral for other personal, language, or job related problems.

We hope this information provides a useful introduction to the WIA Title I program in the Southern Nevada area and that you will successfully reach your career employment goals.



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WC Attachment D Nepotism Form

Last four digits of SS number Participant Last Name, First Name xxx-xx-

Nepotism

1. Is a member of your immediate family (spouse, parent, child, brother, sister, in-law, uncle, aunt, nephew, niece, first cousin, step-parent, stepchild) an elected City or County official?

D Yes D No

If yes, what is his/her name, elected title and relationship to you?

2. Is a member of your immediate family (spouse, parent, child, brother, sister, in-law, uncle, aunt, nephew, niece, first cousin, step-parent, stepchild) an employee of a City, County or WIA Title I funded organization?

D Yes D No

If yes, what is his/her name, organization, position and relationship to you?

By signing this document, I do hereby certify that the information provided is true to the best of my knowledge. I am also aware that I am subject to immediate termination from the WIA Title I funded program if I intentionally supplied inaccurate or misleading information.


Witness Signature Date

Workforce Connections as a recipient of Federal and State funds, is an equal opportunity employment program and is subject to Section 504 of the Rehabilitation Act and the Americans with Disabilities Act (ADA) and Section 188 of the Workforce Investment Act (WIA), and their regulations. You can obtain information about accommodations for disabilities by contacting Workforce Connections offices at (702) 990-3344

=-"""'=~~~~~~~~~~~~~~~~~~~~~~~-

J Workforce Connections Policy ADW-030-05 J J Adult & Dislocated Worker Program

Workforce Connection is an equal opportunity employer/ program.

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WC Attachment E Dislocated Worker Unlikely to Return Affidavit

I, __________________ ,, am unlikely to return to my previous industry (Please print first and last name)

or occupation because:

Check as many as apply:

D No demand for workers in previous field

D Barriers such as physical limitations prevent continuation in past employment

D Lack of skills to successfully accomplish work duties without further training

D Automated technologies have taken over my job functions

D The current job market in this field is very competitive

D Jobs in this industry are limited in this area so re-employment is unlikely

D Uncertain about prospects in this field because the job market is changing

D Other: (pleaseexplainJ _____________________ _


By signing this document, I do hereby certify that the information provided is true to the best of my knowledge. I am also aware that I am subject to immediate termination from the WIA Title I funded program if I intentionally supplied inaccurate or misleading information.

This portion is to be completed by Case Manager or Eligibility representative: Comments:

Program Staff Signature Date

rkforce Connections Polic ADW-030-05 Adult & Dislocated Worker Program

Workforce Connections is an equal opportunity cmpl yer /program.

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WC Attachment F Self Statement

Last four di2its of SS number Participant Last Name, First Name xxx-xx-Purpose:

Please be as specific as possible (statement must be legible).

Program Participant Signature Date By signing this document, I do hereby certify that the information provided is true to the best of my knowledge. I am also aware that I am subject to immediate termination from the WIA Title I funded program if I intentionally supplied inaccurate or misleading information.

This portion is to be completed by Case Manager or Eligibility representative: Comments:

Program Staff Signature Date Note: 1. In the event participant self statement refers to Selective Service Registration requirements please review TEGL 11-11 change 1 and 2 for instructions and acceptable support documentation.

Workforce Connections Polic ADW-030-05 Adult & Dislocated Worker Pro


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WC Attachment G Telephone Verification/ Document Inspection Form

r hil "fl WIA E utll · ity Ver1 1cation b I h 1yTe eu one NVTRAC ID Number Participant Last Name, First Name

Purpose: Date: Time: Contact Person: Phone # (702) E-mail: Fax# (702) Agency providing verification: Address: City: I State: Zip Code: Eligibility Item(s) to be verified:

WIA Staff conducting verification:

WIA Eli "bil" V "fi t" b D • fil •!I er1 ca ion Y: ocumen tin ti spec on NVTRAC ID Number Participant Last Name, First Name

Original Source of Document: Date: Time: Contact Person: Phone# (702) E-mail: Fax# (702) Agency providing verification: Address: City: I State: Zip Code: Eligibility Item(s) to be verified:

Document(s) to be inspected:

WIA Staff conducting verification: CERTIFICATION

I ATTEST THAT THE INFORMATION RECORDED BY ME ON THIS DOCUMENT WAS OBTAINED THROUGH TELEPHONE CONTACT ON THE ABOVE DATE.

OR I ATTEST THAT THE DOCUMENT INSPECTION VERIFIED THE PRIMARY /SECONDARY ITEMS REQUIRED TO DETERMINE ELIGIBILITY FOR THE WIA PROGRAM.

Program Staff Signature Date



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WC Attachment H Selective Service Registration Requirement

Ex . F emptmn orm

Applicant Name:

Date of Birth: Last Four digits of SS#: xxx-xx-

Date entered the U.S. (if applicable):

I , have reviewed the above applicant's documentation and have determined that the applicant's failure to register with Selective Service was not a knowing and willful failure due to the following reason listed below:

D The applicant entered the U.S. after the age of 26.

D The applicant served in the U.S. Armed Forces (copy of DD214 form provided by applicant).

D Evidence was presented indicating that the reason the applicant did not register for Selective Service was "not a knowing or willful failure".

D The applicant was disabled and was continually confined to a residence, hospital or institution.

D The applicant was hospitalized, institutionalized or incarcerated.

D Other: (please be specific)

Comments:

Program Staff Signature: Date



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