U.S. Department of Labor Supplemental Data Sheet for 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 Complete this form for every establishment/work site where you employed workers with disabilities at special minimum wages during your most recently completed fiscal quarter and submit with the Application for Authority to Employ Workers with Disabilities at Special Minimum Wages (WH-226). These establishments/work sites must also be listed on Item 6 of the WH-226. See the next page for instructions for completing this form. 3. This work site is (check one) 1. Name of work site ME Your Main Establishment BR Branch Establishment SE 2. Address of work site Supported Employment Site, Including Enclaves SWEP School Work Experience Program Site 4. Enter the ending date of the most recently completed fiscal quarter for which you are providing information in Items 5 through 9 below 5. Is SCA work performed at this establishment/work site? / YES / NO Below, list all employees with disabilities paid special minimum wages during your most recently completed fiscal quarter. You may submit the following information in alternative formats, for example computer printouts, as long as all the requested information is included. You may attach additional sheets as necessary. 6. Name of Worker with a Disability 7. Primary Disability 8. Type of Work 9. Average Earnings per Hour 10. Enter the Total Number of unduplicated employees who are Employed at this work site and receive special minimum wages 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. American LegalNet, Inc. www.FormsWorkFlow.com Form WH-226A Rev. July 2009 INSTRUCTIONS FOR COMPLETING FORM WH-226A Complete this form for every establishment/work site where you employed workers with disabilities for the work performed at special minimum wages during your most recently completed fiscal quarter and submit with the Application for Authority to Employ Workers with Disabilities at Special Minimum Wages (WH-226). Item 1. Enter the name of the work site/establishment covered by this form. Remember that your main establishment is also considered a work site if workers with disabilities are employed there at special minimum wages. The work site/establishment covered by this form must also appear in either Item 2 or Item 6 of the WH-226. Item 2. Enter the address of the work site covered by this form. This same address must appear in Item 2 or Item 6 of the WH-226. Remember that a separate WH-226A must be submitted for each work site/establishment. Item 3. Indicate the type of work site covered by this data sheet. ME: Your Main Establishment. The establishment named in Item 2 of the WH-226. BR: Branch Establishment. A branch establishment is an establishment or facility operated by the enterprise, that is physically separate from the main establishment, where workers with disabilities are employed at special minimum wages. SE: Supported Employment site, including Enclaves. A supported employment work site is a location, outside of the work center or rehabilitation center, often on the premises of an enterprise separate form 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. SWEP: School Work Experience Program site. 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. Item 4. Enter the date (month/day/year) your most recently completed fiscal quarter ended. This is the quarter for which you are providing information in Items 6 though 9. Item 5. Indicate whether workers with disabilities perform work subject to the Service Contract Act (SCA) at this work site. Item 6. Individually list by name all those workers whose disabilities impaired their productive capacity for the work performed during your most recently completed fiscal quarter and who earned less than the statutory minimum wage or SCA wage determination rate. Item 7. Identify the primary disability of each worker identified in Item 6. You may use the codes provided in Item 5 of the WH-226 or mention the disability by name — for example you could list NM (neuromuscular) or cerebral palsy. Item 8. Clearly identify the primary type of work performed by each worker with a disability. Possible examples include truck helper, assembler, janitor, or machine operator. Item 9. For workers paid hourly wage rates, list the rate or rates paid at the end of the fiscal quarter. For workers paid by piece rates, list the average earnings per hour. Average earnings are computed by dividing the total earnings of the individual worker by the number of hours worked during that fiscal quarter. For example: John Jones earned $900.00 during the quarter ending 6 / 30 / 01. He worked 300 hours that quarter, so his average earnings per hour are $3.00 $3.00 should then be entered in Item 9. The following is an example of how to complete Items 6, 7, 8 and 9: 6. Name of Worker with a Disability 7. Primary Disability 8. Type of Work 9. Average Earnings per Hour John Jones MR Assembles Bags of Bolts $3.00 Robert Smith Neuromuscular Material Handler $3.50 Mary Evans Mental Retardation Janitor $4.15 Item 10. Enter the total number of employees employed at this work site who are paid special minimum wages. Count each employee only once. Remember, each of these employees must be reported in Items 6 through 9. The completed WH-226 and all accompanying form(s) WH-226A should be mailed to U.S. Department of Labor, Wage and Hour Division, Employment Standards Administration, 230 South Dearborn Street, Room 514, Chicago, Illinois 60604. Form WH-226A Rev. July 2009 American LegalNet, Inc. www.FormsWorkFlow.com