Form 2 Form 2 Participating Employee Information

PARTICIPATING EMPLOYEE INFORMATION

This form must be filled out annually with the involvement of the participating employee. For purposes of this form, a participating employee is an employee who is blind or has a significant disability, is working on a contract procured through the AbilityOne Program and is counted towards the mandated annual Direct Labor Hour ratio required for participation in the Program.

This form must be filled out and submitted electronically. The NPA must maintain the individually identifiable data for the employee in its own protected system for purposes of oversight by a Central Nonprofit Agency and/or the Commission, pursuant to Commission Policy 51.400.

Form Reference Number: Click here to enter text.

Note: The form reference number will be randomly generated by the NPA and submitted into the CNA’s electronic data base with the information on this form. The employee’s name associated with the form reference number and any medical documentation concerning the employee are maintained solely by the NPA. The CNA will receive such identifiable information regarding the employee during an oversight visit if this form is reviewed by the CNA. The Commission will receive such information if it does an audit of the CNA’s oversight visit or if it conducts an oversight visit itself.

Current Job Title: Click here to enter text.

Current Job Location/Project: Click here to enter text. NPA Name: Click here to enter text.

1. In the most recent calendar year, what were the total W-2 wages of this employee?

Click or tap here to enter text.

2. What is the current hourly wage of this employee?

Click or tap here to enter text.

3. What type of disability/disabilities does this employee have? Check all that apply. For individuals who qualify for the Program on the basis of blindness, the inclusion of any additional disabilities is voluntary. For individuals qualifying for the Program on the basis of a significant disability, only the disability(ies) relied on to qualify them for the Program are required, and any additional disability disclosure is voluntary.

☐ Blind/Visual Impairment

☐ Developmental Disability

☐ Autism

☐ Cerebral Palsy

☐ Intellectual disability

☐ Other: Click or tap here to enter text.

☐Hearing loss/Deaf

☐ Mental Health Condition

(Check all that apply)

☐ Anxiety disorder

☐ Bipolar disorder

☐ Depression disorder

☐ Post-traumatic stress disorder

☐ Schizophrenia

☐ Other Click or tap here to enter text.

☐ Physical disability

(Check all that apply)

☐ Amputation

☐ Muscular Dystrophy

☐ Musculoskeletal

☐ Spina bifida

☐ Traumatic brain injury

☐ Other Click or tap here to enter text.

4. What accommodations and/or job supports are being provided to this employee? Check all that apply. (For individuals who qualify for the Program on the basis of blindness, the inclusion of any additional supports or accommodations for disabilities other than blindness is voluntary. For individuals qualifying for the Program on the basis of a significant disability, only the accommodations or supports for the disability(ies) relied on to qualify them for the Program are required, and any additional disability supports/accommodations disclosure is voluntary.)

☐ Adaptation to lighting in work environment/building

☐ ASL Interpreter

☐ Assistance with lifting

☐ Assistive Technology

☐ Assistance with problem solving/ decision making

☐ Assistance with transitioning between tasks

☐ Closed Captions

☐ Enhanced training using task analysis, etc.

☐ Ergonomic supports

☐ Job Coach

☐ Modified Task list

☐ Modified Work Schedule

☐ Noise Reduction

☐ Person works remotely

☐ Personal Assistant/Aide Services

☐ Plain language documents

☐ Positioned closer to restroom

☐ Reader/Scribe

☐ Reduced qualitative or quantitative performance standards

☐ Support for Mental Health Conditions

☐ Transportation support

☐ Quiet area/room

☐ Other: Click or tap here to enter text.

☐ Other: Click or tap here to enter text.

☐ Other: Click or tap here to enter text.

5. Are any accommodations or job supports provided by a third party? If so, please specify the third party and the type of accommodation or job support below.

☐No accommodations or job support is being provided by a third party

☐ Yes. Please check all that apply:

☐ VR (Vocational Rehabilitation) 

☐ Medicaid 

☐ VA (Veteran Affairs) 

☐ TTW (Ticket to Work Program) 

☐ School Districts or Systems

☐ Other: Click or tap here to enter text.

List the Accommodation(s) or Job Support(s) Provided (if more than one third party provided an accommodation or job support, identify the third party for each):
Click or tap here to enter text.

☐ None

6. Have any accommodations or job supports provided by the NPA to this employee been reimbursed by a third party? If so, please specify the third party and the type of accommodation or job support below.

☒ No accommodations or job support is being reimbursed by a third party

☐ Yes. Pease check all that apply:

☐ VR (Vocational Rehabilitation) 

☐ Medicaid

☐ VA (Veteran Affairs) 

☐ TTW (Ticket to Work Program) 

☐ School Districts or Systems

☐ Other: Click or tap here to enter text.

Accommodation or Job Support Provided (if more than one third party provided an accommodation or job support, identify the third party for each):
Click or tap here to enter text.

☐ None

7. Question 7 should be answered once the Commission has issued a definition of an Employee Career Plan through its Policy 51.405.

Does this employee have an Employee Career Plan (ECP) as defined by the AbilityOne Commission?

☐ No. If no, check the “No” box below and proceed to question 8.

☐ Yes. If yes, answer questions (a.)-(f.) below, then proceed to question 9.

a. Date of Employee Career Plan

Date: Click or tap to enter a date.

b. If developed prior to the current year, was the plan reviewed with the employee, updated and signed this year?

☐ Yes

☐ No

If yes, when did that occur?

Date: Click or tap to enter a date.

c. What career development activities were provided to this employee, over the past 12 months, pursuant to the employee’s ECP? Check all that apply.

☐ Assistive technology training

☐ Career exploration

☐ Computer training

☐ Disability disclosure training

☐ Job skill development

☐ Mock job interview

☐ Orientation and mobility training

☐ Resume Support

☐ Training classes

☐ Other: Click or tap here to enter text.

d. Did a third party support the development of the employee’s career planning, or the provision of career development activities for the employee, either directly or through reimbursement to the NPA? See options below.

☐ Yes, directly supported by third party

☐ No, not directly supported by third party

If yes, directly supported by third party, check all third parties that apply and complete the text field below.

☐ VR (Vocational Rehabilitation) 

☐ Medicaid

☐ VA (Veteran Affairs) 

☐ TTW (Ticket to Work Program) 

☐ School Districts or Systems

☐ Center for Independent Living

☐ Other Community Group

☐ Other: Click or tap here to enter text.

Activities Provided (if more than one third party provided support, identify the third party for each activity provided): Click or tap here to enter text.
☐ Yes, reimbursed supported by third party

☐ No, not reimbursed supported by third party

If yes, reimbursed by third party, check all third parties that apply and complete the text field below.

☐ VR (Vocational Rehabilitation) 

☐ Medicaid

☐ VA (Veteran Affairs) 

☐ TTW (Ticket to Work Program) 

☐ School Districts or Systems

☐ Center for Independent Living

☐ Other Community Group

☐ Other: Click or tap here to enter text.

8. Has this employee participated in any career development offered by the NPA or by a third party over the past year?

☐ No, employee has not participated in any career development offered by NPA or third party in the past year. (proceed to question 9)

☐ Yes. Please check all that apply.

☐ Assistive technology training

☐ Career exploration

☐ Computer training

☐ Disability disclosure training

☐ Job skill development

☐ Mock job interview

☐ Orientation and mobility training

☐ Resume Support

☐ Training classes

☐ Other: Click or tap here to enter text.

1. Did a third party support the career development either directly or through reimbursement to the NPA?

☐ No other party supported the career development either directly or through reimbursement to the NPA

☐ Yes, directly supported by third party, check all third parties that apply and complete the text field below.

☐ VR (Vocational Rehabilitation) 

☐ Medicaid

☐ VA (Veteran Affairs) 

☐ TTW (Ticket to Work Program) 

☐ School Districts or Systems

☐ Center for Independent Living

☐ Other Community Group

☐ Other: Click or tap here to enter text.

(if more than one party provided support, identify the party for each activity provided): Click or tap here to enter text.

9. Did this employee achieve employee career mobility last year?

☐ Yes Please select the type of mobility achieved.

1. Within the NPA System

☐ Lateral Mobility - Labor position change utilizing different skills but not a promotion.

☐ Upward Mobility - Promotion or labor position change resulting in increased wages or benefits.

2. Outside the NPA System

☐ Employment into Federal/State/Local Government Agency

☐ Employment into Federal/State/Local Contractor

☐ Employment by For-Profit/Non-Profit Employer

☐ Unknow

☐ No Please select from the following

☐ Employee did not achieve mobility.

☐ Employee did not achieve mobility and has affirmatively indicated a desire to remain in their current position.

☐ Employee elected not to pursue mobility due to a concern that increased earnings would result in a corresponding disqualification for a government benefit (such as Medicaid, SSI, or SSDI).

☐ Unknown The employee has achieved mobility, but the NPA has no information about it.

If you wish to include a narrative explaining employee circumstances not covered otherwise in this form, you may do so here: Click or tap here to enter text.

NPA Staff Completing Form

Date: Click here to enter a date. Location/Program: Click here to enter text.

Name: Click here to enter text. Title: Click here to enter text.

Signature:   _________________________