Wtw 2 - Welfare To Work Plan Activity Assignment
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4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
■
PARTICIPANT NAME:
Initial Activity Assignment
■
CASE NAME:
____
Amendment #
WELFARE-TO-WORK PLAN
CASE NUMBER:
I.D. NUMBER:
ACTIVITY ASSIGNMENT
WELFARE-TO-WORK WORKER’S NAME:
ACTIVITIES: Fill out ONE side only. Fill out the left side for plans meeting CalWORKs Welfare-to-Work 24-Month Time
Clock activities. Fill out the right side for plans meeting federal work activities.
Federal Work Activities
Core Activities
■
Unsubsidized employment
for ____ hours
Self-employment
for ____ hours
●
■
Subsidized private or public sector employment
for ____ hours
Grant-based on-the-job training
for ____ hours
●
Work Study
for ____ hours
●
■
Work experience
for ____ hours
■
Community service
for ____ hours
■
Vocational education (12-month lifetime limit)
for ____ hours
■
On-the-job training
for ____ hours
■
Job search and job readiness
(Per established time limits)
for ____ hours
Mental health services
for ____ hours
●
Substance abuse services
for ____ hours
●
Domestic abuse services
for ____ hours
●
■
Providing child care to a community service
program participant
for ____ hours
Non-Core Activities
■
Job skills training directly related to employment
for ____ hours
■
Satisfactory attendance in a secondary school or
in a general educational development course
for ____ hours
■
Education directly related to employment
for ____ hours
Activities Not Meeting Federal
■
Other activities necessary to assist in
obtaining employment
for ____ hours
Total Hourly Requirements
■
I understand that in order for this plan to meet federal participation
requirements, and not count towards my Welfare-to-Work 24-Month
Time Clock, each week I must complete:
■
At least 20 hours of which 20 must be core hours.
■
At least 30 hours of which 20 must be core hours.
■
At least ____ hours of my family’s 35-hour requirement of
which ____ core hours meet my family’s 30-core hour
requirement.
___________(Initial and date)
OR
■
I do not have any months left on my Welfare-to-Work 24-Month Time
Clock. Each week I must complete the hours below or my aid will
be lowered.
■
At least 20 hours of which 20 must be core hours.
■
At least 30 hours of which 20 must be core hours.
■
At least ____ hours of my family’s 35-hour requirement of which
____ core hours meet my family’s 30-core hour requirement.
___________(Initial and date)
WTW 2 (12/12) REQUIRED FORM - SUBSTITUTES PERMITTED
PAGE 1 OF 4
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