SR 12-12 Dated 06/12

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases revisions to the following forms and their associated instructions:

·   Form NHEP102, Notice About Workers’ Compensation Coverage;

·   Example Form NHEP223, Job Search Log Example;

·   Form NHEP232, Work Experience Program (WEP) Agreement; and

·   Form NHEP270, Work Experience Program (WEP) Verification Form.

Participants in the New Hampshire Employment Program (NHEP) are required to engage in certain allowable work activities for a minimum amount of required hours as a condition of eligibility for cash assistance. The Work Experience Program (WEP) placement is such an activity and it provides the WEP participant with real work experience and training. The hours that the participant works in the WEP placement must be recorded and verified on a weekly basis. Additionally, State law requires that all NHEP participants in WEP placements be provided with Workers’ Compensation information.

Form NHEP102, Notice About Workers’ Compensation Coverage, provides the WEP participant, as well as the WEP Host Site, with workers’ compensation information as mandated by state law. Form NHEP232, Work Experience Program (WEP) Agreement, and Form NHEP270, Work Experience Program (WEP) Verification Form, provide information as well as a means for documenting the participant’s job search requirements while participating in an approved WEP activity. The forms revisions released in this SR ensure that the above requirements are being met.

As requested by the Bureau of Welfare to Work and the TANF Unit, Forms NHEP102, Example Form NHEP223, Form NHEP232 and Form NHEP270 have been edited to reflect currently accurate information and revised to be more understandable to both the NHEP participant and the WEP Host Site, if pertinent. This was accomplished by revising any incorrect or outdated information and simplifying the language in the current forms to bring them closer to an 8th grade reading level.

POLICY

Current policy remains unchanged. The NHEP forms revisions released in this SR are editorial in nature and therefore do not impact current policy regarding NHEP WEP placements or participation requirements.

DESCRIPTION OF REVISIONS MADE TO NHEP FORMS

Form NHEP102, Notice About Workers’ Compensation Coverage, is a 1-page, double-sided form, used to inform Work Experience Program (WEP) participants and Host Sites about their Workers’ Compensation coverage while they are participating in an approved WEP activity. The form also provides WEP participants and Host Sites with procedural instructions if the WEP participant experiences any type of work related accident or medical emergency while in the WEP placement.

The NHEP Unit requested that Form NHEP102, Notice About Workers’ Compensation Coverage, be updated on the first page as follows:

·   Both the general information to the individual in the NHEP WEP and the Participant Instructions sections on the first page were reworded to bring the language closer to an 8th grade reading level.

·   The first bullet of the Participant Instructions was edited to remove "another Representative" and "the NHES Manager of the office" as alternate contacts if a WEP is injured.

·   In the second bullet, the NHES Manager was removed as being another person who can determine if the WEP participant is in an approved WEP placement.

·   The phrase "WEP work placement" was changed to "WEP placement" to eliminate redundancy in the third bullet and throughout the rest of the form.

·   The Workers’ Compensation contact information was removed from the 4th bullet and the updated phone number was added to the contact information in the 3rd bullet.

·   The 4th bullet was updated to correct an erroneous reference to a Department of Labor form. The correct name for the on-line form, Notice of Accidental Injury or Occupational Illness, and it’s electronic path for accessing it on the DHHS Knowledge Center, were added to the 4th bullet along with instructions for the WEP to ask the NHEP Representative to access this on-line form if the need arises.

·   Instructions were added for the WEP participant to include or attach their date of birth, telephone number, and home address to Form NHEP102 before submitting it.

Revisions requested by the NHEP Unit continued in the WEP Placement Host Site Supervisor Instructions section on page 2 as follows:

·   The word "supervisor" was added to "Host Site" wherever appropriate to indicate an individual as opposed to a location.

·   The word "work" in the phrase "WEP work placement" was removed throughout the form as being redundant.

·   Instructions for the WEP Host Site Supervisor to use the office’s NHEP Field Support Manager (FSM) as an alternate notification contact in the event of a work related injury was added, and the NHEP Team Members Contact List was listed as a reference for finding NHEP phone numbers.

·   The phone number for the DFA Business and Industry Coordinator was provided as an emergency contact if the Work Host Site Supervisor has misplaced the NHEP Contact List.

·   The language in this section was generally simplified and restructured for clarification.

The usage of Form NHEP102 remains the same, but its associated instructions were updated to explain that:

·   there are no New Heights- generated forms associated with Form NHEP102;

·   there are no translated versions of this form;

·   Field Support Managers may additionally provide this form to WEP participants; and

·   the NHEP Representatives or Field Support Managers must assist the WEP participant by accessing the on-line DHHS form, Notice of Accidental Injury or Occupational Disease, if the participant is injured while working in an approved WEP placement. Directions were also added for finding the form on-line on the DHHS Knowledge Center under Human Resources Information, Health/Safety and Wellness in the Workplace.

Example Form NHEP223, Job Search Log Example, is a one sheet, double-sided form that is an example of a completed Form NHEP223, and is provided to the Job Search participant for assistance in completing Form NHEP223 correctly and timely in order to meet NHEP work participation requirements for financial assistance eligibility and to fulfill federal mandates.

The following changes were made to the front side of Form NHEP223 as requested by the NHEP Unit:

·   The entry for "Time Spent" on 6/27/11 was changed from 4.25 hours to 3.25 hours and the number of "Miles Driven" was changed from 0.0 to 10.0 miles.

·   In the same row, the "Action You Took" that was indicated for the position of Receptionist was changed from "Application/Resume" to "Interview" and the action of "Research/Follow-up" was added to more realistically reflect the time spent for those job search activities.

·   In the "How You Took Action" section, again for 6/27/11, the "On-line/Fax" indication was removed from the "Receptionist" position and a check mark was added to the "In Person" column.

·   At the bottom of the first page, Monday’s total hours were changed from 4.25 to 3.25 and Friday’s total hours were changed from 3.0 hours to 2.0 hours.

·   The Row Total and Column Total were both changed from 23.25 to 21.25 hours.

Updates to the back side of Form NHEP223 that were requested by the NHEP Unit are as follows:

·   The figure in the "Time Spent" column for 7/01/11 was changed from 3.0 hours to 2.0 hours.

·   The number of "Miles Driven" for each of the 3 entries on 6/29/11 was changed for consistency to 9.0 miles, since all 3 businesses are in the same location.

·   Check marks were added to the "Research/Follow-up" column in the "Action You Took" section for both 6/30/11 and 7/1/11.

Form NHEP232, Work Experience Program (WEP) Agreement, is a 1-page, double-sided form that must be completed for all WEP placements. It is used to:

·   establish an agreement for up to 16 weeks between the New Hampshire Employment Program (NHEP), the WEP participant, and the WEP Host Site or to extend an already existing WEP agreement;

·   define the parties involved, special requirements, job title, participant duties and responsibilities and scheduled work days and times;

·   obtain the participant’s agreement to the Work Experience Description which includes the WEP’s duties, responsibilities and weekly schedule;

·   outline the general provisions and reporting requirements of the WEP agreement;

·   document signatures of all parties involved which, in return, validates NHEP WEP participants being appropriately covered in the state’s worker’s compensation coverage; and

·   ensure that the participant has been provided with information regarding rights in the work place and worker’s compensation coverage.

Form NHEP232 was updated on Page 1 by request of the NHEP Unit as follows:

·   The word "Dept" was replaced with "NHEP Representative" in the shaded banner at the top of the page.

·   The term "Work Host" was replaced with "Host Site" in the left-hand heading at the top of the page and throughout the rest of the form wherever appropriate.

·   Under the new Host Site heading, "Name" was replaced with "Supervisor", "Work Site" was replaced with "Company", an extra line was added for the address, a new line designated "Fax #" was added between the "Phone #" and "E-mail" lines, and "Work Host" was removed from the authorized signature line and replaced with "Host Site Supervisor".

·   Under the NHEP Representative heading at the top right of the first page, an extra line was added for the address.

·   In the Reporting Requirements section, "Host Site" was used as the lead in phrase and replaced "Work Host" throughout, the 6 reporting requirements that were previously numbered were reorganized in a bulleted list, the WEP participant was added as someone who has the right to terminate the WEP Agreement at any time, and "up to 16 weeks" was specified as the length of time for which the WEP Agreement can be established.

The General Provisions section on Page 1 was revised by:

·   replacing the term Work Host with Host Site in the section’s lead in sentence; and

·   adding the word "WEP" in front of the word "participant" in the second provision.

In the first page footer, the distribution instructions were removed, since this form is no longer produced as a 3-part NCR form.

The NHEP Unit additionally requested that Page 2 of Form NHEP 232 be revised by:

·   adding a line for designating the WEP participant’s Career Path at the top of the page;

·   replacing "SOC Code" with "ECS use only";

·   adding check-off boxes for "20 hours", "30 hours" or "other", to denote the total number of hours to be worked per week;

·   adding "FLSA" to the "Maximum Weekly Hours Allowed" headings for in both the 4-week month and the 5-week month schedules listed;

·   updating both work schedules by changing "Scheduled Work Days and Times" to "Weekly Schedule" and replacing "From (hours)" and "To (hours)" with "Daily Start Time" and "Daily End Time";

·   listing each work week in both schedules as beginning on Saturday and ending on Friday, instead of Sunday through Saturday;

·   adding the word WEP to the Participant’s Signature line; and

·   removing the distribution instructions from the footer at the bottom of the page.

The work schedules on Page 2 were changed to better capture the maximum number of hours that can be required of a WEP participant in both a 4-week and 5-week month. To ensure compliance with federal mandates, every WEP placement will require the development of two separate work schedules, one for a 4-week month and one for a 5-week month, in accordance with Fair Labor Standards Act (FLSA) requirements.

Form NHEP232(i) was updated accordingly. There are no changes in the way this form will be used, but additional revisions were made to the form’s instructions to indicate that there are no New HEIGHTS-generated forms associated with Form NHEP232 and the form has not been translated.

Additionally, since Form NHEP232, Work Experience Program (WEP) Agreement, will no longer be printed as a 3-PART NCR form, new distribution instructions were added for using the updated version of the form. The NHEP Representative will make copies of the form and distribute them to the appropriate recipients, if requested, per current policy.

Form NHEP270, Work Experience Program (WEP) Verification Form, is a one-page, single-sided form used by NHEP participants to verify their weekly participation in Alternative Work Experience Program (AWEP) and Community Work Experience Program (CWEP) activities. The form is distributed and reviewed by the NHEP team member.

AWEP and CWEP activities are supervised daily and must be verified on a weekly basis. Review of this form, along with ongoing assessments of the individual, will assist the NHEP team member in determining if the individual is complying with their Employability Plan.

Revisions by request of the NHEP Unit were made to Form NHEP270 and are as follows:

·   In the shaded banner near the top of the page, "For Dept. Use Only" was removed and new check off boxes denoting both FLSA 4-week and 5-week months were added.

·   "Work Host" was replaced with "Host Site" throughout the form.

·   "NHEP Team Location" was replaced with "Host Site Supervisor" under the 3rd line in the top right fill-in section.

·   The language in the instructions in the middle of the form was simplified for clarification and to bring it closer to an 8th grade reading level.

·   The attendance chart was reconfigured to be more easily understood and also as follows:

o Blank date spaces (__/__/__) were added for indicating the "Week Beginning" date as well as the date for each day of that work week; and

o The work week was changed from Sunday through Saturday to show that the work week begins on Saturday and ends on Friday.

·   "Work Host" was replaced by "Host Site" in both the affirmation and under the Host’s signature line.

Form 270(i) was updated accordingly. The usage of this form remains the same, but the instructions were updated to note that there are no New Heights-generated versions of the form and it has not been translated.

IMPLEMENTATION

Continue using old versions of Forms NHEP102, Example Form NHEP223, Form NHEP232 and Form NHEP270 until supplies are exhausted. Once the current supplies of Forms NHEP102, Example Form NHEP223, Form NHEP232 and Form NHEP270 have been depleted, the new versions will be available from the DHHS warehouse in the usual manner, via the QFO. The forms are also available electronically, for Department staff only, on the Lotus Notes Family Services and Knowledge Center Databases.

CLIENT NOTIFICATION

No client notification is necessary.

TRAINING

No training is needed.

FORMS MANUAL POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed or deleted after its contents have been noted and the SR has been posted to the On-line manual.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR, and revised On-Line Manuals, will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at www.dhhs.nh.gov/DFA/publications.htm, effective July 2, 2012. Additionally, this SR will be distributed under separate cover to all internal hard copy holders of the Forms Manual.

DFA/KD:s