West Piedmont Workforce Investment BoardProvider … · On-the-Job Training Plans may require...

The West Piedmont Workforce Investment Board and sub-recipients are equal opportunity employers/programs. Auxiliary aids and services are available upon request to individuals with disabilities. Primary source of funding is from the U.S. Department of Labor Employment and Training Administration.

West Piedmont Workforce Investment Board Provider ServicesWIOA/OJT Operator On-the-Job Training (OJT) Application

Section 1: General Information:

Please Complete the Following WIOA/OJT REPRESENTATIVE NAME: PHONE/EMAIL:

TRAINEE NAME: JOB TITLE:

O*NET CODE: SVP CODE: MAXIMUM TRAINING HOURS:

REIMBURSEMENT RATE:

$

MAXIMUM REIMBURSABLE AMOUNT:

$

HOURLY STARTING WAGE:

$

HOURLY ENDING WAGE:

$ COMPANY NAME: COMPANY ADDRESS:

TRAINEE SUPERVISOR: TITLE: PHONE/EMAIL:

EMPLOYER REPRESENTATIVE NAME: TITLE: PHONE/EMAIL:

PAY SCHEDULE: Weekly Monthly

Bi-Weekly Other

PAY DAY:

PERIOD COVERED:

RATIO OF TRAINEES TO SUPERVISOR:

BENEFITS AVAILABLE:

Section 2: Training Outline List in the chart below the skills and learning objectives needed to become proficient in the position. Note: the standard training hours are determined through the use of SVP codes while the actual anticipated training hours are determined after careful analysis of the trainee’s current skills and work history. Please list the standard and anticipated hours required for each skill, as well as the estimated start and end dates. The midpoint and final evaluations will address all listed skills and learning objectives. Attach an official job description to the completed contract.

SKILLS/LEARNING OBJECTIVES STANDARD TRAINING

HOURS

ANTICIPATED TRAINING

HOURS

ESTIMATED START DATE

ESTIMATED END DATE

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Section 3: Authorized Signatures

By signing below, I agree to adhere to the Training Outline and my responsibilities thereof. EMPLOYER SIGNATURE: TITLE: DATE:

TRAINEE SUPERVISOR SIGNATURE: TITLE: DATE:

TRAINEE SIGNATURE TITLE: DATE:

WIOA/OJT AGENCY REPRESENTATIVE SIGNATURE: TITLE: DATE:

Section 4: Training Plan Modification, If Applicable

On-the-Job Training Plans may require changes for which a modification is necessary. Reasons for a modification include but are not limited to:

x To extend the end date of training due to illness or equipment failures at the place of businessx To correct errors in the original training budget or the description of the job duties.x Cancellation of training due to trainee, worksite, or budgetary issues.x To extend the end date in order to ensure satisfactory skill attainment.

The employer and the OJT Agency agree that this Training Plan shall be modified as stated:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Except as hereby modified, all other terms and conditions of this training plan remain unchanged and in full force and effect. The

effective date of this modification is_______________.

The employer and the WIOA/OJT Agency mutually agree to abide by the terms and conditions stated and do hereby execute this modification in keeping with our respective authority.

By signing below, I agree to adhere to the modifications set forth in Section 4

EMPLOYER SIGNATURE TITLE: DATE:

SUPERVISOR SIGNATURE TITLE: DATE:

TRAINEE SIGNATURE TITLE: DATE:

WIOA OJT AGENCY REPRESENTATIVE SIGNATURE DATE:

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West Piedmont Workforce Investment BoardWIOA Operator On-the-Job Training (OJT) TRAINEE EVALUATION & INVOICE FORM

Section 1: General Information: EMPLOYER NAME: CONTACT PERSON: TELEPHONE#:

EMPLOYER ADDRESS: ALTERNATE TELEPHONE:

Section 2: Trainee Information TRAINEE NAME: EMAIL: TELEPHONE #:

JOB TITLE: HOURS PER WEEK: WEEKS:

OJT BEGINNING DATE: OJT END DATE: TOTAL TRAINING HOURS:

HOURLY WAGE RATE: REIMBURSMENT RATE (Not to exceed $12.20/hour:

MAXIMUM REIMBURSEMENT

COMPLETE IF RAISES ARE AWARDED DURING TRAINING REVISED HOURLY WAGE RATE:$

TRAINING HOURS/REVISED RATE:

REVISED MAXIMUM REIMBURSEMENT:$

Section 3: Reimbursable Hours Worked Complete the calendar with the trainee’s reimburse hours worked for the invoice time period. Fill in the date and reimbursable hours worked for each applicable day for the invoice time period. Information recorded here should only include reimbursable hours. Reimbursement for the extraordinary costs of training will be based on a % of the standard wage as outlined in the OJT contract.

Note: As outlined in the OJT contract, holidays, sick time, vacations, overtime, weekend pay, etc. will not be reimbursed. Use this calendar to only record reimbursable hours for the invoice period.

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Date Hours Date Hours Date Hours Date Hours Date Hours Date Hours Date Hours

PAY PERIOD FROM: TO:

TOTAL HOURS TO BE REIMBURSED:________________ TOTAL AMOUNT TO BE REIMBURSED:____________

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Section 4: Authorized Signatures I hereby certify that the information is, to the best of my knowledge, true and correct. TRAINEE SIGNATURE AND INFORMATION EMPLOYER SIGNATURE AND INFORMATION TRAINEE (PRINT NAME): EMPLOYER NAME/TITLE (PRINT):

TRAINEE SIGNATURE: EMPLOYER SIGNATURE:

DATE: DATE:

For Official Use Only

EMPLOYER REIMBURSEMENT AMOUNT HOURLY

RATE x RATE OF

REIMBURSEMENT = HOURLY RATE OF

REIMBURSEMENT x REIMBURSEMENT

HOURS = AMOUNT

DUE EMPLOYER:

CUMULATIVE EMPLOYER PAYMENT

CUMULATIVE OJT HOURS WORKED

CUMULATIVE REIMBURSEMENT PAID

TO EMPLOYER

MAXIMUM AMOUNT

POTENTIAL BALANCE REMAINING

WIOA/OJT PROVIDER SIGNATURE AND INFORMATIONWIOA/OJT REPRESENTATIVE (PRINT NAME):

WIOA/OJT REPRESENTATIVE SIGNATURE:

DATE:

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WEST PIEDMONT WORKFORCE INVESTMENT Board (WPWIB)Provider Services, WIOA/OJT OPERATOR On-the-Job Training (OJT) Contract: Trainee Evaluation

TRAINEE NAME: SUPERVISOR NAME: COMPANY NAME:

Evaluation

SKILLS/LEARNING OBJECTIVES MIDPOINT

EVALUATION OF SKILLS

MIDPOINT EVALUATION

DATE

FINAL EVALUATION OF

SKILLS

FINAL EVALUATION

DATE

Mastered objective Satisfactory progress Unsatisfactory progress
















Section 2: Authorized Signatures Midpoint Evaluation Final Evaluation

I hereby certify that the above information is accurate. I hereby certify that the above information is accurate.

EMPLOYER SIGNATURE: DATE: EMPLOYER SIGNATURE: DATE:

SUPERVISOR SIGNATURE: DATE:

SUPERVISOR SIGNATURE: DATE:

TRAINEE SIGNATURE: DATE: TRAINEE SIGNATURE: DATE:

☐ Having satisfied the requirements of the training plan, employment continues on an unsubsidized basis.

Please explain any unsatisfactory evaluation:

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COMPLETION/TERMINATION NOTICE

Contracting Employer:_____________________________ Location:________________________________________ OJT Enrollee: ____________________________________

S : _____________

Completed On-the-Job Training: Yes ___ No ___ Still Employed: Yes ___ No ___

Date Completed: ________/________/_______ (Month) (Day) (Year)

Wage after OJT completion: $_____________/hour

Termination Information: Date of Termination ________/________/________ (Month) (Day) (Year)

Reason (check one): Discharge ____ Qu it _ ___ Entered School ____ Health ____

The West Piedmont Workforce Investment Board and sub-recipients are equal opportunity employers/programs. Auxiliary aids and services are available upon request

to individuals with disabilities. Primary source of funding is from the U.S. Department of Labor Employment and Training Administration.

WPWIB December 2016

6 OJT Application

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