Example Import Workers Templates June 12

Name of
worker

How many
jobs did
this worker
perform at
this work
site?

Average #
of hours
worked
per week
on all jobs
at this
work site

Average
earnings
per hour
for all jobs
at this
work site

Type of work
performed (for
employees
working more
than one job, use
job employee
worked most
hours at
subminimum
wage)

Primary disability
that affects
productivity for
job described in
(e). Pick only one:
IDD; PD; VI; HI; SA;
NM; AR; or OT (if
OT, specify). See
instructions for list
of primary
disabilities.

Sue Gomez 1

22

10.65

SCA laundry
contract

John Jones 3

10.15

3

Bolt hand
assembly

Primary
disability:
If other,
specify

Prevailing
wage rate
for job
described
in (e)

Productivity
measure/
rating for job
described in
(e)

Commensu
rate wage
rate/
average
earnings
per hour
for job
described
in (e)

Total
hours
worked for
job
described
in (e)

Does
worker
perform
work for
this
employer
at any
other work
site? (yes/
no)

Intellectual/Develo
pmental Disability
(IDD)

16.42

64.8

10.65

22

Yes

Neuromuscular
Disability (NM)

10.15

n/a - piece rate 3.38

65

No