SUPPORTIVE SERVICE FORM



AttachmentChapter 4. Part 2: Youth Program ActivitiesParticipant File Monitoring ChecklistSubrecipient NameParticipant Name (First and Last Name)Contract NumberParticipant CalJOBS WIOA Application #Type of Youth Program FORMCHECKBOX OSY FORMCHECKBOX ISYEnrollment DateReviewed by (First and Last Name) Date of File ReviewDate of BirthPlease indicate (yes, no or n/a) if meeting the criteriaMEDICAL INFORMATIONYesNoN/ACommentsNo medical information is stored in the participant file -including eligibility/program information on disabilities, request for reasonable accommodation, medical, or mental health informationMay be kept in a separate, secure file or electronically in CalJOBS FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????ELIGIBILITYYesNoN/ACommentsEligibility Certification Review Form (ECRF)Correct version of formAll sections completeDates & signatures PRIOR or AT enrollmentEligibility expiration date within 90 days FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????DocumentationRegion & address FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Social Security Number FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Date of birth & age FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Right to work FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Selective service (if applicable) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Veteran’s priority (if applicable) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????School status FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Employment barriers (At least one must be verified in CalJOBS) FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Low Income Determination Documentation (if applicable)Does the youth have a barrier that requires low-income determination? FORMCHECKBOX Yes FORMCHECKBOX No (If not, skip this section)Youth received, or is a member of a family which receives cash payments under a federal, state, or income-based public assistance program; FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????A youth is low-income if he or she receives or is eligible to receive a free or reduced price lunch under the Richard B. Russell National School Lunch Act (42 U.S.C. 1751 et seq.); FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Living in high poverty area; or FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????The youth is receiving SNAP or was determined eligible to receive food stamps in the six-month period prior to program application FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Family size and income determination FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Youth with disabilities income determination (for ISY only) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Other Eligibility Documentation (if applicable)5% Eligibility Exception Request FormCorrect version of the formAll sections completeDates & signatures PRIOR or AT enrollmentApproved by SDWP Program Specialist FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Applicant Statement and Telephone VerificationCorrect version of the formAll sections completeDates & signatures PRIOR or AT enrollmentCase notes in CalJOBS Note: When using an Applicant Statement, there must be a separate form for each circumstance and a corresponding case note for each form (not to be combined). FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Foster Youth Programs FORMCHECKBOX Enrolled in San Pasqual Academy FORMCHECKBOX Enrolled in the County of San Diego's Independent Living Skills Program FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????ENROLLMENT YesNoCommentsUniversal Participant Agreement Form (UPAF)Correct version of the formAll sections completeDates & signature PRIOR or AT enrollmentMinors <18 signed by parent or legal guardian FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Multimedia Publicity/Privacy Release FormCorrect version of the formAll sections completeDates & signature PRIOR or AT enrollmentMinors <18 signed by parent or legal guardian FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????CalJOBS Data ValidationEligibility & enrollment information matches in CalJOBS FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????LITERACY/NUMERACYYesNoCommentsHas the youth been tested for Basic Skills Deficient? FORMCHECKBOX Yes FORMCHECKBOX No (If not, skip this section)Documentation Original answer sheetDatedType of test noted (i.e. Pre/Post) FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????CalJOBS Data EntryActivity codes (Reference CalJOBS Activity Codes)Separate from Objective Assessment/ISSCalJOBS Case notes for: FORMCHECKBOX Eligibility; FORMCHECKBOX Objective assessment; and/or FORMCHECKBOX Measurable skills gain FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????OBJECTIVE ASSESSMENT YesNoCommentsCalJOBS Data EntryObjective Assessment completed in CalJOBS within 30 Days after enrollmentAll sections complete, if applicableCalJOBS Activity Code 412 Opened on WIOA App during EnrollmentClosed within 30 DaysCase Note that Objective Assessment was completed in CalJOBSCompleted prior to receiving servicesNo updates after 30 days FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????INDIVIDUAL SERVICE STRATEGY/EMPLOYMENT PLAN (ISS/IEP)YesNoCommentsCalJOBS Data Entry - OriginalISS/IEP completed in CalJOBS within 30 Days after enrollmentCalJOBS Activity Code 413 Opened concurrently or after 412Closed within 30 daysCase Note that ISS was completed in CalJOBSCompleted prior to receiving services FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????CalJOBS Data Entry - UpdatesCalJOBS Activity Code 413 Updated every 3-6 months, or sooner if neededCase Note that ISS was updated in CalJOBS FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????CalJOBS Data Enry - Closing Goals & ObjectivesGoals/Objectives are closed as successful/unsuccessful prior to program exit FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????SELECTIVE SERVICEYesNoN/ACommentsMales who turn 18 while receiving program services must register for selective service with 30 days after their birthday FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????PROGRAM SERVICESYesNoN/ACommentsActive and consistent engagement with participantCalJOBS activity codes and case notes are complete and accurate FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Provides at least one of the Program Components(Includes the 14 required elements) FORMCHECKBOX Educational Services FORMCHECKBOX Career Pathways FORMCHECKBOX Work Readiness Training FORMCHECKBOX Work Experience Opportunities FORMCHECKBOX Youth Development FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Attempts to re-engageIf youth is not actively engaged, then attempts to re-engage are entered in CalJOBS with a case note FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????WORK EXPERIENCEYesNoCommentsHas the youth participated in work experience? FORMCHECKBOX Yes FORMCHECKBOX No (If not, skip this section)DocumentationWork permit from the school (if applicable)I-9 Employment Eligibility VerificationW-4 Employee’s Withholding Allowance CertificateWorksite Agreement & Training PlanTimesheets (see criteria below)Documentation may be available in the following: FORMCHECKBOX Participant file FORMCHECKBOX Youth service provider records FORMCHECKBOX Third party staffing agency FORMCHECKBOX Payroll processing agency FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Documentation – TimesheetsTimesheets must be paper or electronic, at minimum, and include the following:Start and end of each work periodMeal periods takenSplit shift intervalTotal hours worked daily and for total pay periodNo overtime hours allowedInitials from participant and supervisor if changes madeNo whiteoutTimesheets approved by supervisor FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????CalJOBS Data EntryCalJOBS Activity code (Reference CalJOBS Activity Codes)CalJOBS Case notes FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????INCENTIVESYesNoN/ACommentsHas participant received incentives? FORMCHECKBOX Yes FORMCHECKBOX No (If not, skip this section)DocumentationAn incentive plan was developed and approved by the Workforce Program Specialist before incentive is paid out.Incentive Log & Receipt Form completedIncentive receipt such as check, gift card with serial number or non-cash award. No gift cards for entertainment activities FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????CalJOBS Data EntryActivity code (Reference CalJOBS Activity Codes) Case notes include type of incentive, amount of incentive and reason for incentive FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Justification for receiving an incentive should be linked to a goal on the ISS and participant should only receive an incentive after successfully completing a milestone. FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????The youth must acknowledge the receipt of incentive payment and formal acknowledgement must be maintained in participant file. FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Timesheets or attendance records, if applicable, are maintained to support the incentive paidTimesheets are signed by the participant and his/her supervisorAny changes on time sheets are initialed by the participant or the supervisor FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????STIPENDSYesNoN/ACommentsHas the participant received stipends? FORMCHECKBOX Yes FORMCHECKBOX No (If not, skip this section)A stipend plan was developed and approved by the Workforce Program Specialist before stipends are given.Stipend Log & Receipt Form Completed FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????If the stipend paid is based on the hours of participation, the stipend paid is below the Federal or California State minimum hourly wage, whichever is higher. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Evidence, such as participation or attendance records, or certification of achievement, are maintained to support that the participant met the terms and conditions of the stipends paid. FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Evidence document(s) (i.e., timesheet, attendance records, or certification of achievement) are signed by the participant and supervisor. FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Any change of time sheets or attendance records are initialed by the participant or his/her supervisor. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????The payment is not based on online or virtual participation. FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????The ISS has specified the goal or criteria that must be met to earn the stipends. FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Justification for the payments of stipends is documented in the participant file. FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????The type of payment method and amount is specified in the participant file. FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????A worksheet showing how the payment amount was calculated is maintained in the participant file. FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Activity code is entered into CalJOBS. FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????SUPPORTIVE SERVICESYesNoCommentsHas the participant received supportive services? FORMCHECKBOX Yes FORMCHECKBOX No (If not, skip this section)Determination of need:Listed on the ISSBased on results of objective assessmentAllowable supportive services may include: FORMCHECKBOX Housing/shelter FORMCHECKBOX Transportation FORMCHECKBOX Clothing/uniforms FORMCHECKBOX Work related tools/equipment FORMCHECKBOX License/certification fees FORMCHECKBOX Optical needs such as eyeglasses or protective eye gear FORMCHECKBOX Short term child care FORMCHECKBOX Other needs related to training or employment retention FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????DocumentationSDWP Supportive Service Log & Receipt FormItemized receipt of purchaseTransportation: copy of bus pass with serial numberTransportation: determination of distance (map)Gas card: Mileage tracking log FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????CalJOBS Data EntryActivity codes (reference CalJOBS activity code list)Case notes include:Type of supportive services, Amount expended, Link to program activities such as educational or employment related activities. FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????PERFORMANCEYesNoN/ACommentsDoes participant have performance outcomes? FORMCHECKBOX Yes FORMCHECKBOX No (If not, skip this section) FORMCHECKBOX PLACEMENTPlacement includes any of the following (1st, 2nd, & 4th quarters after exit):Education Occupation Skills TrainingUnsubsidized EmploymentApprenticeshipMilitaryCalJOBS Data EntryOutcome form is completedCase notes include information regarding outcome FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Documentation in case file (If applicable) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Median Earnings Gain (2nd quarter after exit)Documented wages under the 2nd quarter placement measure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX ATTAINMENTAttainment includes any of the following (2nd quarter after exit):Recognized postsecondary credentialOther recognized credentialSecondary school diploma or its recognized equivalent and must have a placementCalJOBS Data EntryOutcome form is completedCase notes include information regarding outcome FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Documentation in case file FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX MEASURABLE SKILLS GAINMeasurable Skills Gain includes any of the following (if youth is in an education or training program and must be attained within program year):Educational Functioning level (EFL) gainSecondary Diploma/EquivalentTranscript/Report cardTraining milestoneSkills progressionCalJOBS Data EntryOutcome form is completedCase notes include information regarding outcome FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Documentation in case file FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????GLOBAL EXCLUSIONS YesNoN/ACommentsWas the participant exited with a global exclusion? FORMCHECKBOX Yes FORMCHECKBOX No (If not, skip this section)Documentation in case fileReasons for global exclusions: FORMCHECKBOX Health/medical FORMCHECKBOX Residing in an institution or facility providing 24-hour support FORMCHECKBOX Deceased FORMCHECKBOX Reservist called to Acive Duty FORMCHECKBOX Relocated to a Mandated Program (Foster Youth) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????CalJOBS Data EntryClosure form completeCase notes include information regarding global exclusion FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????FOLLOW UP SERVICES YesNoN/ACommentsIs the participant exited and in follow up services? FORMCHECKBOX Yes FORMCHECKBOX No (If not, skip this section)Quarter 1 Completed FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Quarter 2 Completed FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Quarter 3 Completed FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Quarter 4 Completed FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????CalJOBS Data EntryActivity codes (reference activity code list F series)Case notes regarding follow up status FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Attempts to engageCalJOBS case notes with attempts to contact FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? ................
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