2009 Worksite Request

* = Required.

Company Name:

Work Location:

Address:

Telephone:

Fax:

County:

Email:

Status

Contact Person

Local Tax District of Employment

Do you Sub-Contract Any Services?

If Yes, Please List Jobs

Were you a 2008 Summer Worksite?

Comments

WORK EXPERIENCE OPPORTUNITIES
Work experience opportunities may operate between:
In School: 5/1/09 - 9/30/09 Out of School: 5/1/09 - 3/31/10

Job Title

# Needed

Supervisor(s)
Name / Title /Experience

Alternate Supervisor(s)
Name / Title / Experience

Can you provide a consistent Work Experience?

If No, Please Explain

Supervisor(s) from your organization are required to attend supervisor(s)/alternative supervisor training
on one of the following dates located at

PA CareerLink Lehigh Valley
1601 Union Blouvard, Allentown from 1:30 - 3:30 p.m.
Please indicate number of attending on the date you select.

Date Attending

# Attending

Work hours may be up to 35 hours per week.
Lunch is not paid and not counted as work hours.
Please indicate start time, lunch period, and end time.

Job Title

Responsibilities

Start
hh:mmxx

Lunch
hh:mmxx

End
hh:mmxx

Please list or attach Job Qualifications, Job Requirements and/or Job description(s).

You may request a specific individual for any of your work experience opportunities.
Please provide the name, phone number of any indivuals you request.

Name:

Phone:

SAFETY ISSUES
Safety equipment will be provided within reason, ie. gloves, goggles, safety shoes, etc.
Organizations must provide their own operational equipment and first aid kit.

Will participants be transported in co. vehicle?

If Yes, Indicate date, location, status of youth.

Participants daily reporting Location(s):

If outdoor work is being considered what are your inclement weather plans?

Is there a collective bargaining unit ?

Bargaining Unit

Categories Covered

Expiration Date

Bargaining Unit Representative

Address

Telephone Number

If your organization provides work experience for multiple youth and would like to be considered for
financial assistance for supervisory services, please explain and justify your request below.
Request will be considered based on funding availability.

Full time employment opportunities?

If Yes, Please describe:

ASSURANCES AND CERTIFICATIONS

The Worksite hereby acknowledges, and agrees to comply with, the following statutory, regulatory and policy provisions:

A. DISPLACEMENT OF CURRENTLY EMPLOYED WORKERS: The Worksite assures that no currently employed worker shall be displaced by any participant, including partial displacement such as a reduction in hours of non-overtime work, wages or employment benefits. No participant shall be employed or job opening filled when (a) any other individual is on layoff from the same or any substantially equivalent job, or (b) when the Worksite has terminated the employment of any regular employee, or has otherwise reduced its work force with the intention of filling the vacancy so created by utilizing a participant.

B. HEALTH AND SAFETY STANDARDS: Health and safety standards applicable to working conditions of participants shall be equally applicable to working conditions of the regular employees. The Worksite assures that appropriate standard for health and safety will be maintained, including adherence to both federal and state laws.

C. SECTARIAN ACTIVITIES: The Worksite assures that participants will not be employed in building, operating, or maintaining any part of any building, which is used for religious instruction or worship.

D. COLLECTIVE BARGAINING AND UNION ACTIVITIES: The Worksite assures that this agreement will not impair existing contracts for services or collective bargaining agreement between the Worksite and other parties, nor will this agreement assist, promote or deter union organization.

E. LOBBYING AND POLITICAL ACTIVITIES: The Worksite assures that this agreement will not assist with political or lobbying activities or the cost of any salaries or expenses related to any activity designed to influence legislation or appropriation pending before the Congress of the United States.

F. EQUAL OPPORTUNITY: The Worksite will not discriminate against any employee because of race, color, religion, sex, or national origin.

G. AMERICANS WITH DISABILITIES ACT (ADA): Worksites must be ADA compliant.

H. ACT 33/34 CHECKS/CLEARANCES AND FEDERAL CRIMINAL HISTORY RECORDS: Any person who directs the activities of youth under the age of 18 whether a primary or alternate supervisor is required to receive Act 33/34 clearances (Criminal Background Check and Child Abuse Clearance) and Federal Criminal History Records. Please indicate if these checks/clearances/records have been received by supervisor(s) and if copies are maintained at your organization.

If not, please explain:

I. CHILD LABOR LAWS: Must comply with child labor laws, minimum wage laws, and all applicable employment rules and laws.

J. SUPERVISION: Responsible for Worksite supervision of young adults. Responsible for attending supervisor(s) and alternate supervisor(s) training.

K. PARENTAL PERMISSION: All off site activities require prior parent/guardian approval.

Submitted with the approval of the Chief Executive Officer of the organization.

I agree:

Date

Name

Title

Submit Clear