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‐NEG@labor.ny.gov  

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‐NEG@labor.ny.gov  

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‐NEG@labor.ny.gov 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 OJTDueDiligence@labor.ny.gov. 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