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* = Required.

Company Name

Work Location:

Address:

Telephone:

Fax:

County:

Email:

Status:

Contact Person(s) Name & Title:

Local Service Tax District of Employment Site:

Were you a 2010 Worksite?

Participants' Daily Reporting Location(s):

WORK EXPERIENCE OPPORTUNITIES
Work Experience Opportunities May Operate Between:
7/1/11 - 6/30/12

Job Title

Industry
Cluster

#
Needed

Supervisor(s)
Name/Title/Experience

Alternate Supervisor(s)
Name/Title/Experience

PLEASE INDICATE WHICH LEHIGH VALLEY TARGETED INDUSTRY CLUSTER THESE JOB TITLES FOCUS ON?
Click here to SELECT INDUSTRY CLUSTERS

Can you provide an uninterrupted Work Experience?

If no, please explain:

Any Supervisor(s) from your organization that will supervise participants are required to attend supervisor(s)/alternative
supervisor(s) training on one of the following dates located at PA CareerLink Lehigh Valley, 1601 Union Boulevard,
Allentown from 1:30 - 3:30 p.m. Please indicate number of attending on the date you select.

Date Attending:

# Attending

WORK SCHEDULE
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
Time
hh:mmxx

Lunch
Time
hh:mmxx

End
Time
hh:mmxx

Hours
Per
Week

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 and phone number of any individuals you request.

Name:

Phone:

AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE CHECKLIST

DESCRIPTION OF TRAINING/WORK FACILITY

Organization Name:

Date:

Address:

Description of Space and Innovative Equipment Utilized:

Access to public transportation

Access to computers (if applicable)

Accommodations for lunch

Adequate bathroom facilities

Adequate heating

Adequate lighting

Adequate ventilation

Availability of air conditioning

Availability of desks, tables and chairs (if applicable)

Conducive to a learning, safe and drug-free environment

Safety:

fire escape(s)/stairwell(s)

fire exit(s)

fire extinguisher(s)

smoke alarm(s)

Will display equal employment opportunity and other required postings

Are fifteen or more people employed here?
IF YES, PLEASE COMPLETE THE FOLLOWING:

Is your building over one level?

Do you have an elevator?

Do you have handicapped accessible parking?

Do you have ramp access into your building?

Are your doors wide enough for wheelchair access (at least 32 inches clear)?

Are your restrooms handicapped accessible with at least one fully accessible
restroom (one for each sex, or one unisex)?

Are the restroom doorways at least 32 inches clear?

Are restroom doors equipped with accessible handles
(operable with a closed fist)?

Is there a wheelchair accessible stall with enough space to make turns?

Are there grab bars behind and on the side wall nearest the toilet?

Can the faucet be operated with one closed fist?

Comments (Explain all "No" answers):

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 work experience participants be transported in a company vehicle?

Are any work experience activities planned off site?

If yes, indicate approximate date and location

Will your verhicle liability and insurance cover the participants?
If your answer is no, participants cannot be transported.

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

Is there a collective bargaining unit for employees?
If yes, please answer the following:

Bargaining Unit

Categories Covered

Expiration Date

Bargaining Unit Representative

Address

Telephone Number

Do you currently have any full time employment opportunities available?

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: The Worksite assures 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 an 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 No, please explain

I. CHILD LABOR LAWS: The Worksite assures compliance with child labor laws, minimum wage laws, and all applicable employment rules and laws.

J. SUPERVISION: The Worksite is responsible for worksite supervision of young adults and is also responsible for attending mandatory supervisor(s) and alternate supervisor(s) training.

K. SUBCONTRACTED SERVICES: If a work experience involves work for and/or supervision by a subcontractor of your organization, then the subcontractor must complete a worksite request.

L. 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