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Supplemental Data Sheet for Application for

U. S. Department of Labor

Wage and Hour Division

Authority to Employ Workers with Disabilities

Employment Standards Administration

at Special Minimum Wages

230 South Dearborn Street, Room 514

Chicago, Illinois 60604

_______________________________________________________________________________________________________________________________________________

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Note:

Persons are not required to respond to this collection of information unless it displays a currently valid OMB

OMB No.: 1215-0005

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control number.

Expires:

12/31/2007

Complete this form for every establishment/worksite 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/worksites must also be listed on Item 6 of the WH-226. See the reverse side for instructions for

completing this form.

1. Name of Worksite:

_______________________________

3. This worksite is (check one)

_____ ME:

Your Main Establishment

2. Address of Worksite: _______________________________

_____ BR:

Branch Establishment

_______________________________

_____ SE:

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/worksite?

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

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

We estimate that it will take an average of 45 minutes per response to complete this collection of information, including time for reviewing instructions, searching existing

data sources, gathering and maintaining the data needed, and completing and reviewing the collection information. If you have any comments regarding this burden estimate

or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the U. S. Department of Labor, Administrator, Wage and

Hour Division, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C., 20210 (please do not send the completed form to this address).

WH-226A

January 2002