Worksite Request

Worksite

A worksite providing a work experience for participants may be in the private, for-profit, the non-profit sector or the public sector. These sectors include business and industry, municipalities, townships, community and faith-based organizations, and educational institutions.

The workforce board Lehigh Valley’s goal is to provide work experience in high priority occupations in the Lehigh Valley’s targeted industry clusters.

Work Experience

Work experiences are planned structured learning experiences that take place in a workplace for a limited period of time.

Company Name*

Work Location

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

County*

Phone*

Fax

Email

Status

Contact Name*

First Last

Contact Title

Have you been a Worksite in the past?

Yes
No

Participants' Daily Reporting Location(s)

Work Experience Opportunities

Job Title	Industry Cluster	# Needed	Supervisor(s) Name/Title/Experience	Alternate Supervisor(s) Name/Title/Experience

Industry Cluster

Can you provide an uninterrupted Work Experience?

Yes
No

If no, please explain

Work Schedule

Work hours may be up to 28 hours per week.
Lunch is not paid and not counted as work hours.
Please indicate start time, lunch period, and end time.

Work Schedule

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.

Requested Contact Name

First Last

Requested Contact Phone

Americans With Disabilities Act (ADA) Compliance Checklist

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Description of Space and Innovative Equipment Utilized

Access to public transportation

Yes
No

Access to computers (if applicable)

Yes
No

Accommodations for lunch

Yes
No

Adequate bathroom facilities

Yes
No

Adequate heating

Yes
No

Adequate lighting

Yes
No

Adequate ventilation

Yes
No

Availability of air conditioning

Yes
No

Availability of desks, tables and chairs (if applicable)

Yes
No

Conducive to a learning, safe and drug-free environment

Yes
No

Fire escape(s)/stairwell(s)

Yes
No

Fire exit(s)

Yes
No

Fire extinguisher(s)

Yes
No

Smoke alarm(s)

Yes
No

Will display equal employment opportunity and other required postings

Yes
No

Are fifteen or more people employed here?

Yes
No

Is your building over one level?

Yes
No

Do you have an elevator?

Yes
No

Do you have handicapped accessible parking?

Yes
No

Do you have ramp access into your building?

Yes
No

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

Yes
No

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

Yes
No

Are the restroom doorways at least 32 inches clear?

Yes
No

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

Yes
No

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

Yes
No

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

Yes
No

Can the faucet be operated with one closed fist?

Yes
No

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?

Yes
No

Are any work experience activities planned off site?

Yes
No

If yes, indicate approximate date and location

Will your verhicle liability and insurance cover the participants?

Yes
No

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?

Yes
No

Bargaining Unit

Categories Covered

Expiration Date

Bargaining Unit Representative

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Do you currently have any full time employment opportunities available?

Yes
No

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.

Acknowledge

Yes
No

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*

First Last

Title