U.S. Department of Labor Application for Authority to Employ Workers with Disabilities at Special Minimum Wages Employment Standards Administration Wage and Hour Division 230 South Dearborn Street, Room 514 Chicago, Illinois 60604 OMB No.: 1215-0005 Expires: 01-31-2011 This is an application for the authority to employ workers with disabilities at special minimum wage rates under the Fair Labor Standards Act (FLSA), Walsh–Healey Public Contracts Act (PCA), or McNamara–O’Hara Service Contract Act (SCA). An instruction sheet for completing this form is contained on page 4. Please submit one copy of the completed form, and any attachments, to the address shown above. Retain a completed copy for your records. A certificate may not be granted by the Department of Labor unless a properly completed application has been received and approved. 29 U.S.C. § 201, et seq. For USDOL Use Only 1. a. This is a request for authority to employ workers with disabilities for (Check All Boxes that Apply): Certificate Number Community Rehabilitation Center (Work Center) Effective Date Hospital/Residential Care Facility (Patient Workers) Business Establishment (Special Workers) / Expiration Date RO School Work Experience Program (SWEP) / / / DO Remarks Employees b. This is (Check One): Paying SMW’s Yes No Initial Application (Complete All Items) Number of sites to receive a certificate Renewal Application (Please Make Any Necessary Corrections to Reprinted Information) Print Certificate Current Certificate Number: 6. List the name and address(es) of all branch establishments (BR), supported employment sites, including enclaves (SE), or school work experience program sites (SWEP) to be covered by this certificate. Note: A separate Supplemental Data Sheet (WH-226A) must be completed for every establishment where you employ workers with disabilities at special minimum wages (including your main establishment and each establishment listed below). See page 4 of this application for definitions of BR, SE and SWEP. Attach additional sheets if necessary. 2. Name of Employer Street Address Mailing Address (If Different than Street Address) City Indicate if BR, SE or SWEP County State Yes WS No Name & Address of Site Zip Code Federal Employer Identification Number (EIN) Person USDOL should contact Telephone ( ) 3. Parent Organization if different from that listed in #2: Name Address 7. Do you manufacture items for the Federal Government under PCA? Check here if mail is to be sent to parent organization rather than #2. Yes No Do you perform any services for the Federal Government under SCA? 4. Status (Check One): Yes Public (State or Local Government) Private, For Profit Private, Not For Profit Other No 3 Remember to attach copies of all current SCA Wage Determinations for those contracts upon which workers with disabilities are employed and earning special minimum wages. 5. Primary Disability Group Employed (Check One): Mental Retardation (MR) Alcoholism (AL) General — No Primary Group (GI) Mental Illness (MI) Drug Addictions (DA) Age Related (AR) Visual Impairment (VI) Neuromuscular (NM) Other (OT) Specify: Hearing Impairment (HI) Developmental Disability (DD) Specify: (continued on next page) Form WH-226 Rev. July 2009 American LegalNet, Inc. www.FormsWorkFlow.com 8. FOR RENEWAL APPLICATIONS ONLY Please provide the number of workers with disabilities (whose productive capacities were impaired by their disabilities and were paid special minimum wages) that your firm employed during your most recently completed fiscal year. Please provide this data using the categories listed below. Number of Workers Employed in or as (Complete Each Item as Applicable): Work Center Patient Worker Business Establishment Also Provide the Date Your Most Recently Completed Fiscal Year Ended: / SWEP / 9. PREVAILING WAGE DETERMINATION Please provide the following information on the four largest current contracts whether the workers with disabilities are paid an hourly rate or a piece rate. The prevailing rate should reflect the rate paid to experienced workers in the vicinity who do not have disabilities and utilize similar methods and equipment. If more than 3 sources were used, attach an additional sheet headed “Prevailing Wage Determination” and provide the information obtained from these sources (FLSA section 14 (c)(2)(B) and 29 C.F.R. § 525.10). Description of Work (e.g., Collating, Hand Assembly, Janitorial) Sources (Name of Firm and Person Contacted) Date of Contact Prevailing Wage Provided by Source 1. $ 2. $ 3. $ 1. $ 2. $ 3. $ 1. $ 2. $ 3. $ 1. $ 2. $ 3. Prevailing Wage Determined by Applicant $ $ $ $ $ 10. FOR RENEWAL APPLICATIONS ONLY — HOURLY RATES a. How many workers with disabilities employed under the terms of this certificate received special minimum wages and were paid hourly rates during the fiscal year cited in Block 8 above? (If the answer is 0, go on to question 11.) b. How frequently do you rate/evaluate the productivity of each hourly paid worker with a disability who is paid a special minimum wage? c. Attach to this application productivity rating /evaluation forms for three currently employed workers with disabilities who are paid hourly rates (if you employ workers with disabilities at special minimum wages on an SCA contract, one of the three employees for whom data is submitted must pertain to an SCA service employee). Include all material relating to the evaluation which shows the worker’s individual productivity in proportion to the wage and productivity of an experienced worker, who does not have disabilities, performing essentially the same type, quality and quantity of work in the vicinity. 11. FOR RENEWAL APPLICATIONS ONLY — PIECE RATES a. How many workers with disabilities employed under the terms of this certificate received special minimum wages and were paid piece rates during the fiscal year cited in Block 8 above? (If the answer is 0, go on to question 12.) b. Please provide the following information about the four largest current contracts on which workers with disabilities earning special minimum wages are paid piece rates and attach supporting time studies or work measurements. Description of Work (e.g., Packaging, Shrink Wrapping, Labeling) Prevailing Wage Determined for This Job (Expressed in a Rate per Hour) (continued on next page) Standard Productivity (Units /Hour) Piece Rate Paid to Workers (Rate per Unit) Form WH-226 Rev. July 2009 American LegalNet, Inc. www.FormsWorkFlow.com 12. REPRESENTATIVE PAYEE FOR SOCIAL SECURITY BENEFITS Check if your facility is a representative payee for any worker with disabilities and, as such, receiving Social Security Benefits such as SSI or SSDI on behalf of that employee. 13. CREDITING THE REASONABLE COST OF FACILITIES PROVIDED TOWARD MEETING THE MINIMUM WAGE OR SPECIAL MINIMUM WAGE Section 3(m) of the Fair Labor Standards Act permits employers, under certain circumstances, to count toward its minimum obligations the reasonable cost of furnishing facilities which are customarily furnished to employees. Check the box if you are crediting the cost of providing facilities, such as board, lodging, and transportation, toward meeting your minimum wage or special minimum wage obligations to workers with disabilities. 14. TEMPORARY AUTHORITY: To be completed only by a vocational rehabilitation program administered by a State agency or the U.S. Veterans Administration. Check if this is a request for temporary authority to employ workers with disabilities at special minimum wages pursuant to a vocational rehabilitation program of the Veterans Administration for veterans with a service-incurred disability or a vocational rehabilitation program administered by a State agency. A copy of the signed application will constitute the temporary authority provided the application is mailed to the Department of Labor at the address listed at the top of page 1 of this form within ten days of the signing. Temporary authority will exist for 90 days from the date the application is signed and cannot be extended or renewed by the issuing agency. (See 29 C.F.R. § 525.8 and instructions on page 4 of this application.) 15. REPRESENTATIONS AND WRITTEN ASSURANCES I certify that I have read this form and to the best of my knowledge and belief, all answers and information given in the application and attachments are true; that the representations set forth in support of this application to obtain or continue the authorization to pay workers with disabilities at subminimum wage rates are true; and I acknowledge that the authorization, if issued or continued, is subject to revocation in accordance with the provisions of 29 C.F.R. part 525. I represent that as set forth in the regulations governing the employment of workers with disabilities, the following conditions exist and will continue to exist: 1) Workers employed under the authority in 29 C.F.R. part 525 have disabilities for the work to be performed; 2) Wage rates paid to workers with disabilities under the authority in 29 C.F.R. part 525 are commensurate with those paid experienced workers, who do not have disabilities, in industry in the vicinity for essentially the same type, quality, and quantity of work; 3) The operations are and will continue to be in compliance with the FLSA, PCA, SCA, and Contract Work Hours and Safety Standards Act (CWHSSA), an overtime statute for federal contract work, as applicable; 4) No deductions will be made from the commensurate wages earned by a patient worker to cover the cost of room, board or other services provided by the facility; 5) Records required under 29 C.F.R. part 525 with respect to documentation of disability, productivity, time studies or work measurements, and prevailing wage surveys will be maintained. Further, I certify that: 1) The wage rates of all hourly-rated employees paid in accordance with FLSA section 14(c) will be reviewed at least every six months; and 2) Wages paid to all employees under FLSA section 14(c) will be adjusted at periodic intervals, at least once a year, to reflect changes in the prevailing wage paid to experienced workers, who do not have disabilities, employed in the vicinity for essentially the same type of work. 16. SIGNATURE OF AUTHORIZED REPRESENTATIVE Name (Print or Type) Title Signature Date Public Burden Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The Department of Labor estimates that the public reporting burden for this collection of information will average 45 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is mandatory in order to obtain the authority to pay less than the applicable minimum wage. 29 C.F.R. §§ 525.7-9, 12-13. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Avenue, N.W., Washington, DC 20210 and reference the OMB Control Number. SEND THE COMPLETED SURVEY TO THE ADDRESS ON THE FRONT OF THE FORM. Form WH-226 Rev. July 2009 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTION SHEET GENERAL INSTRUCTIONS ) 1 This application is to be used to apply for a subminimum wage certificate under the Fair Labor Standards Act (FLSA), the Walsh–Healey Public Contracts Act (PCA), and the McNamara–O’Hara Service Contract Act (SCA). Payment of subminimum wages to workers with disabilities is authorized only under certificates issued under FLSA section 14(c). State Agencies and the Veterans Administration may also request immediate temporary certificate authority by completing this application. 2) Complete one copy of this form and send it to the following address: U.S. Department of Labor, Employment Standards Administration, Wage and Hour Division, 230 South Dearborn Street, Room 514, Chicago, Illinois, 60604. Telephone: (312) 596-7195 Keep a copy of the application for your records. 3) For item #1: A community rehabilitation center (often in the past referred to as a sheltered workshop) is a facility that is engaged primarily in providing rehabilitation and employment opportunities to workers with disabilities. A patient worker is a worker with a disability who is employed by a hospital or institution that provides residential care where such worker receives treatment and care. A business establishment, for purposes of this application, is an employer in private industry (who is not a work center or employer of patient workers) that is seeking permission to employ workers with disabilities at special minimum wages. A school work experience program (SWEP) is a school operated program by which students with disabilities may be placed in jobs with private industry within the community. ) 4 Do not submit a separate application for each branch establishment, supported employment work site (including enclaves), or school work experience site. Instead, report these in the spaces provided in Item 6 and complete and submit a separate form WH-226A for each site where workers with disabilities are (will be) employed at special minimum wages. If you operate a work center and employ patient workers, you will receive two separate certificates. Likewise, you will receive separate certificates for each branch establishment and school work experience program site for which you completed a WH-226A. Workers with disabilities paid special minimum wages who work at supported employment sites, including enclaves, however, are covered by the certificate issued the main establishment of the supervising work center. For item #6: A branch establishment is a physically separate establishment of the same enterprise. A supported employment work site is a location, outside of the work center or rehabilitation center, often on the premises of an enterprise separate from the work center or rehabilitation center, where workers with disabilities paid special minimum wages are placed in employment settings along with work center staff (job coaches). An enclave is a supported employment work site where a group of workers with disabilities is working and supervised by staff from the work center. A school work experience program (SWEP) site is a workplace in the community in which a school system has placed a student(s) with disabilities to work in a job(s) at special minimum wages. SPECIAL INSTRUCTIONS FOR SCHOOL WORK EXPERIENCE PROGRAMS (SWEPS) The rehabilitation counselor or coordinating official of the school may submit a group application covering all of the students with disabilities and all of the employers participating in a school work experience program. Employers are responsible for compliance with all applicable child labor laws, minimum wage standards, certificate and recordkeeping requirements. The students participating in a school work experience program must be paid commensurate wage rates based upon the students’ productivity in proportion to the wage and productivity of experienced workers who do not have disabilities performing essentially the same type, quality, and quantity of work in the vicinity in which the students are employed. Complete all items except 12. Item 1(A) Check “School Work Experience Program” Item 2 Enter identifying information for school Item 3 Enter School District information Item 4 Check “Other” and Enter “SWEP” Items 9 and 11 Complete for the four types of work in which the greatest number of students with disabilities are employed at special minimum wages. If fewer than four types of jobs exist, enter “n/a” in the “Description of Work” blocks which are not used. Item 16 Must be signed by the Counselor or Coordinating Official of the school SPECIAL INSTRUCTIONS FOR VOCATIONAL REHABILITATION COUNSELORS OR VETERANS ADMINISTRATION TRAINING OFFICERS REQUESTING IMMEDIATE TEMPORARY CERTIFICATION TO PAY SPECIAL MINIMUM WAGES Complete All Items of This Application. Item 1(A) Check “Business Establishments (Special Worker)” Item 2 Enter name and location of employer where workers with disabilities are to be placed Item 3 Enter the name and address of the Veterans Administration Office or State vocational rehabilitation agency which is seeking temporary authority Item 4 Check “Other” and enter the type of business in which the worker with a disability is being placed Items 9 and 11 Complete for the work sites where the workers with disabilities will be employed at special minimum wages Item 14 Check the box Item 16 Must be signed by the Vocational Rehabilitation Counselor or Veterans Administration Training Officer Form WH-226 Rev. July 2009 American LegalNet, Inc. www.FormsWorkFlow.com