l I ,I 4'' YTH-040-05 - WorkforceConnections [1] .pdf · General Policies YTH-040-05 Record Retention ... information form. ... disability, political affiliation, or belief, [WIA

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Workforce Connections General Policies YTH-040-05 Record Retention Pro~ram Participant File ~

R evil ,ed.; i\.ugust 2014

Policy Approved By: WC Executive Director \ 1'

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Policy Adopted on: November 2013 \ v.

Purpose: 1\J

To establish the Workforce Connections' (WC) Policy foli Youth Programs 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. Service Providers may establish written internal 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 retained by the funded partner for a period of at least five (5) years subsequent to the date of submission of final grant expenditure report, close-out package as of the date all audits are complete and finding and/or all claims have been resolved, whichever occurs first. This policy applies to all Workforce Connections Service Providers providing WIA Title I services to Youth program participants.

Reference: [PL 105-220 Sec.136 (f) (3)][29 CFR §95.53][29 CFR §97.42][29 CFR §97.2o(b) (6)] [WIA State Compliance Policy 5.4]

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 PolicyYTH-040-05 1 1 WC-Youth Programs

Workforce Connections is an equal opportunity employer/program.

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Addendum-1

I. General Provisions Limitation of Public Access to Records

A. 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.

B. 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:

1. The Department of Labor 2. The Governor 3. State Workforce Investment Support Services division (WISS) 4. Local WIA Title I recipients (WC Service Provider(s)) 5. Local WIA Title I sub-recipients (WC Service Provider(s)) 6. Appropriate governmental authorities involved in the administration ofWIA 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.

I Workforce Connections Policy YTH-040-05 11 WC-Youth Programs


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Addendum-1 Continuation

i. 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 Service Strategy (ISS) development and advise them that their social security number is 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.

B. 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 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 adult, dislocated workers or youth funded program by Workforce Connections.

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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 confidentially as possible and should not require 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, or cannot be 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 PolicyYfH-040-04, Data Recording and Management item I(C)(l), 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-Youth Start -> Here

Section IV Related Needs

1. Supportive Services Log

2. SS support documents

3. Incentive Service Log 4. Incentive Service Docs.

Section I Eligibility

1. Cover Page or Check List

2. NVTRAC-EDR

3. Nevada State Residence

4.SSN

5.SSR

6. I-9form

7. E.O Notice

8. Rights and Responsibilities

9. WIA required forms - Table A

10. WIA Youth program application

SectionV Training Activities

1. Training

2. OJT-WEX

3, Attendance records

4. Timesheets

5, Copy of Payments

6. Copy of Invoices

7. Copy of SGA

8. Copy of Training Plan

Section II Career

Objective Goals 1.Assessment

2.ISS

3. CASAS/TABE 4. School Docs


Section Ill Progress

1. NVTRAC - PPR

2. NVTRAC -Case Notes

' 3. Follow-Up

Section VI Outcomes

1. Employment verification

2. Diploma/Certificate/Credential

3. Lit/Num Gains (OSY)

WC-Youth Pro rams


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VI. Program Participant Files - Support Documentation - Table A Section I - Elig!bili!l'.

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Youth General Eligibility Criteria Acceptable Support Documentation

(Veri~ each criterion unless s_Qecified otherwise) (Onl::x: one document oer eligibili!Y criterion is required) ll-~~~--~~--~~----~--.-c~~~~-vb--le--~~-'-'--"'~~~~~~~-'--'-~

Birth Date/ Age

U.S. Work Authorization

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

Card Cl Official Hospital Record of Birth 0 Passport Cl Public Assistance/Social Service Record Cl School Record Cl Alien Permanent Resident Card Cl Work Permit

0 Verification Document(s) that satisfy List A of the I-9 form 03-08-2013 N OMB N. 1615-0047 Expires 03-31-2016 Note: For Changes to the list of acceptable identity

and work authorization documents, go to : www.uscis.gov/i-gcentral or www.uscis.gov

0 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

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.

0 Selective Service Acknowledgement Letter 0 Form DD-214 "report of separation" Cl Selective Service Registration Verification form, can be

found at: www.sss.gov 0 Selective Service Status Information Letter Cl Selective Service Registration Card Cl Selective Service Registration Record (form 3A) Cl Selective Service Verification form Cl Stamped Post Office Receipt of registration 0 Self Statement - TEGL 11-11Change1 and 2

WIA - Workforce Connections Required Forms 0 0 0 0 0 0 0 a 0 0

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NVTRAC - Eligibility Determination Printout - Properly Signed and Dated1

Equal Opportunity is the Law - Attachment A Release of Information Form - Attachment B Participant Rights and Responsibilities - Attachment C Nepotism Form -Attachment D Self-Certification - Attachment E Telephone Verification Form -Attachment F Medical and Emergency Consent Form - Attachment G Income Statement -Attachment H WIA Youth Program Ai:> lication

1 Participant and program staff signatures must appear m this pnntout.

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Eligibility Criteria

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Youth- (Continued)


Acceptable Support Documentation (Verify each criterion unless specified otherwise) (Only one document per eligibili'ty criterion is required)

Low-Income

D Pay Stubs D Income Employment Verification D Social Security Benefits Letter D Compensation Award Letter

1. Individual and/or Family Income D Pension Statement D Bank Statements D Family or Business Financial Records D Quarterly tax statement for Self-Employed D Other (must specify)

D Birth Certificates

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D Public Assistance Records (e.g., copy of payment records) 2. Verification of Family Size D Welfare Letter

D Medicaid Cards and/ or records D Telephone Verification D Other (must specify)

D FS Public Assistance Record - Household Summary D Potential Applicant Self-Statement

3. Public Assistance - Food Stamps (FS) D Benefits Award Letter Addressed to potential applicant D Cross-Match with Public Assistance Records - check link:

www.access.nevada.gov.access D Other (must specify)

D Cash Public Assistance Record - Household Summary D Benefits Award Letter Addressed to potential applicant

4• Cash- Public Assistance (TANF) D Telephone Verification D Cross-Match with Public Assistance Records - check link:

www.access.nevada.gov .access D Other (must specify)

D Refugee Assistance Records D Cash Public Assistance Record - Household Summary

5 • Other - (RCA, SSI, GA) D Benefits Award Letter Addressed to potential applicant D Telephone Verification D Other (must specify)

I Workforce Connections PolicyYTH-040-05 11 WC-Youth Programs


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- Eligibility Criteria

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Youth- (Continued)


Acceptable Support Documentation (Verify each criterion unless s1>ecified otherwise) (Only one document per eligibility criterion is required)

Elig!bility Criteria

0 Standardized Test: e.g., CASAS/TABE - dated and scored 0 School IEP for In-School Youth - supporting case notes

6. Basic Skills Deficient must be present 0 School Records 0 Other (must specify)

0 School Attendance Records 0 Letter Properly Signed and Dated by School Officials

7 • School Dropout 0 Potential Applicant Self-Statement 0 Dropout Letter 0 Other (must specify) 0 Potential Applicant Self-Statement

8 • Homeless or Runaway 0 Letter from Shelter/Social Service Agency 0 Letter Properly Signed/Dated from Individual Providing

Temporanr Residency

9 • Foster Child OR Aged out of Foster Care 0 Letter from State or Local Agency or Foster Home 0 Potential Applicant Self-Statement

at18 0 Other {must specify) 0 Birth Certificate(s) or Hospital Record of Birth 0 Physician's Paperwork confirming pregnancy

10. Pregnant or Parenting 0 Child Baptismal Records 0 Potential Applicant Self-Statement 0 Other (must specify) 0 Court Documents 0 Letter from Pre-Release Center

11. Offender D Letter from Parole Officer or Probation Officer 0 Police Records 0 Potential Participant Self-Statement 0 Other (musts ecify)

Veterans' Priori:9_'. for Service Elig!bility Verification

Priority of Service Veteran D DD-214

Eli&.ible Covered Pers2n§ 0 Cross Match with VA

Must Meet WIA priority of service to apply Spouse 0 VA Verification letter instead of DD-Veterans' Priority of Service 214 ..... ~

Youth-(Continued) --Eligibility Criteria Acceptable Support Documentation

(Verify each criterion unless specified otherwise) (Onl)I: one document per eligibility criterion_ is required) Social Security Number 0 Copy of Social Security Card

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Section 1(a) of this policy 0 Letter from the Social Security Administration showing SSN Item II(4)(a)(b) 0 Copy of W-2 form Note: 1. 0 DD-214 form 0:: J 0 Employment records )

0 UI record ~IJ I



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Section II - Career Objectives Goals -~-------~~~

Services _Activity

-~-(Ensure and verify proper completion)

WC Policy YTH-040-02 Youth Objective Assessment Individual Service Strategy WIA standardized test

Youth- (Continued) Required Support Documentation

D Fully executed D Properly signed and dated by participant and Case Manager D Must demonstrate participants' career - objective goals D Must show target dates for accomplishment D Must show follow-up and URdates

Section III-WC MIS-NVTRAC PPR/WC MIS-NVTRAC Case Notes re:portLfollow-u:p -- Youth - (Continued) Data Collection Required Support Documentation

(Ensure and verify timely and accurate reporting) WC Policy YTH-040-04 Youth Data Requirements D Program Participation Report (properly signed and dated)

D Case notes report printout (at least once a month)

Section IV - Related Needs

- Youth - (Continued) Supportive Services Required Support Documentation

(Ensure and verify justification for provision) WC Policy YTH-040-06 D Properly completed supportive services log Supportive Services D Copy of properly signed and dated voucher(s)

D Must be documented in ISS WC Policy YTH-040-07 D Copy of record(s) related to payments Incentives D Case manager determination of need

D Case noted justification

Section V -Training Activities -~-----Youth - (Continued)

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

OJT - WEX WC Policy YTH 040-08 D Fully executed pre-award check list - attachment A D Fully executed skill gap analysis - attachment B D Fully executed training plan - attachment C D Fully executed OJT contract D Must be linked to participants' career/objective goals - ISS D Case manager determination of need D Case noted justification D List of additional required support documentation on WC -

D-------~-~~-~~-------co--~~P~o_li~cy~YfH-040~~0_8_W~EX~------~~---~~ D Fully executed Individual Training Authorization ITAs -Training D Properly completed ISS D Printout from WC ETPL D List of additional support documentation on WC - Policy

ADW-030-06

WC-Youth Pro rams


Section VI - Outcomes

Performance and Outcomes Progress - Achievements

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Youth- (Continued)

Addendum-I Continuation

Required Sup_port Documentation 0 Copy of certificate of completion 0 Copy of diploma 0 Copy of credential(s) 0 Income verifications 0 Follow up related paper work - retention 0 Literacy [Numeracy gain verification

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 always be substituted for the original records, 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

[] If any litigation, claim, or audit is started before the expiration of the five (5) 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 54].

[] 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 §g5.53( e)] and [WIA State Compliance Policy 5.4].



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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 John Thurman-Northern 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 (TTY, Nevada Relay 711) D Mary Beth Hartleb, Southern NV Workforce Investment Board EO Officer (702) 638-8750 and (800)

326-6868 (TTY, Nevada Relay 711) ~

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WC Attachment B Release of Information

I, , do hereby give Workforce Connections and its' designees permission to obtain and release information related to my employment and/ or education.

Em loY!llent information to be obtainedLreleased a Date of employment a Job title a Wagerate a Full time/part time status a Hours per week a Benefits received and reason for their

termination (if a licable)

1 Education information to be obtained/ released

a Date of enrollment in training program a Date of diploma/certificate attainment a Type of diploma a Type of certification/credential(s) a Attendance records Cl Schoolrecords Cl Progress

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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:

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

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

Parent/Guardian or Responsible Adult Date


Wo1·kforce Connections is an equal opportunity employer/program.

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WC Attachment C Program Participant Rights and Responsibilities

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Welcome and thank you for your interest in the Workforce Investment Act (WIA) -Youth Program! We sincerely hope that we are able to assist you with your Education, Training and 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-Youth Program representatives for clarification or help.

Participant Rights

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

0 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 Service Strategy.

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 Service Strategy.

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 YTH-040-05 11

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 program activities, orientations, assessments, designed to help you attain your career goals.

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. 0 Accept any reasonable offer of

employment. 0 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.

WC-Youth Programs


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WIA-Youth Program is an Educational/Training and Employment 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 and/or determine what type of services will successfully lead to attain your career goals. Looking for employment, high school diploma/GED, or in need of vocational training? 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 and education 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 career goals.

I understand that by signing my name, I am agreeing to comply with the Individual Service Strategy developed today. I understand that the Workforce Investment Act Youth Program is agreeing to help me to achieve my career goals as quickly as possible, and will provide supportive services to assist me as long as I am in compliance with the Individual Service Strategy developed today. I understand that I may request changes in the Individual Service Strategy by contacting my Case Manager.

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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 Youth 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.

By signing this document, I do hereby certify that I have received a copy of the rights and responsibilities information sheet. My case manager has explained these rights and responsibilities to me and I fully understand them. I understand that a full copy of this information sheet is available to me upon request.

Participant Signature Date

Program Staff Signature Date

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NVTRAC ID Number

Nepotism

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WC Attachment D Nepotism Form

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 American 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) 0-33A4 __ _

rce Connections Polic YI'H-040-05 WC-Youth Pro rams


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Applicant Name:

Address:

Last Four (4) Digits of SS#:

Phone Number:

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WC Attachment E Self-Certification Form

I City/State:

Application Date:

Alternative Number:

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


r Zip Code:

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.

Parent/Guardian or Responsible Adult Date:

This portion is to be completed by Case Manager or eligibility representative: ~~~~~~~~~

Comments: The above self-certification information is being utilized for the following Eligibility Criteria:




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WC Attachment F Telephone Verification/Document Inspection Form

WIA Elig!bili!}' Verification by Tele~hone NVfRAC ID Number Participant Last Name, First Name

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

WIA staff conducting verification:

I!;! I I en cation b D ~ ocumen ti t• ns_pec ion NVfRAC ID Number Partici~ant Last Name, First Name

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

Document(s) to be inspected:

WIA staff conducting verification: CERTIFICATION

I ATI'EST 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.




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WC Attachment G Medical and Emergency Consent Form

Date:

Participant Name:

Parent/Legal Guardian Name:

Address:

Phone Number/Home:

Phone Number/Mobile:

Phone Number/Work:

Phone Number/Other:

EMERGENCY CONTACT Name:

Relationship:

Address:

Phone Number/Home:

Phone Number/Mobile:

Phone Number/Work:

Phone Number/Other:

I hereby authorize and request that medical treatment be performed as required. This would include transportation to a medical emergency center site(s) in the Las Vegas area. I hereby authorize the release of my personal information to [service provider name], Workforce Connections and/ or partnering agency program(s). I have read, understand and voluntarily sign this form.

Applicant Signature

Parent/Guardian or Responsible Adult (If Applicant is under 18 years of age)

Workforce Connections Polic YTH-040-0

Date

Date

WC-Youth Pro rams


--Name:

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WC Attachment H Income Statement

FamilY' SizeLFamily Income Last four (4) digits of SS# xxx-xx-

-Address: City/State: Zip Code:

Application Date:

- To be completed by WIA pro~am staff

Family Member's Name Relationship to Applicant Family Member Income Last Six (6) Months

$

$

$

$

$

$

Total Number in Family: Total Income: $ -In the event family members not currently residing in applicant's residence, please complete the following:

f N=e Reason

Applicant Certification: By signing this document, I do hereby certify that the information provided is true to the best of my knowledge. I agree that any information that I have supplied is subject to verification. 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.

Applicant Signature Date

WIA Staff Certification: By signing this document, I do hereby certify that the information provided by program participant is true to the best of my knowledge.

WIA Staff Name: _ ____________ _ Date: _ _ _______ _

Signature: - ----- - ------- --

Support Documentation: YesD NuO



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