Form Wh-226 - Application For Authority To Employ Workers With Disabilities At Special Minimum Wages - 2008 Page 2

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8. FOR RENEWAL APPLICATIONS ONLY
Please provide the number of workers with disabilities (whose productive capacities were impaired by their disabilities and were paid special minimum
wages) that your firm employed during your most recently completed fiscal year. Please provide this data using the categories listed below.
Number of Workers Employed in or as (Complete Each Item as Applicable):
Work Center
Patient Worker
Business Establishment
SWEP
Also Provide the Date Your Most Recently Completed Fiscal Year Ended:
/
/
9. PREVAILING WAGE DETERMINATION
Please provide the following information on the four largest current contracts whether the workers with disabilities are paid an hourly rate or a piece rate. The
prevailing rate should reflect the rate paid to experienced workers in the vicinity who do not have disabilities and utilize similar methods and equipment.
If more than 3 sources were used, attach an additional sheet headed “Prevailing Wage Determination” and provide the information obtained from these
sources (FLSA section 14 (c)(2)(B) and 29 C.F.R. § 525.10).
Description of Work
Prevailing Wage
Prevailing Wage
(e.g., Collating, Hand
Sources
Date of
Provided
Determined by
Assembly, Janitorial)
(Name of Firm and Person Contacted)
Contact
by Source
Applicant
1.
$
2.
$
$
3.
$
1.
$
2.
$
$
3.
$
1.
$
2.
$
$
3.
$
1.
$
2.
$
$
3.
$
10. FOR RENEWAL APPLICATIONS ONLY — HOURLY RATES
a. How many workers with disabilities employed under the terms of this certificate received special minimum wages and were paid hourly rates during
the fiscal year cited in Block 8 above? (If the answer is 0, go on to question 11.)
b. How frequently do you rate/evaluate the productivity of each hourly paid worker with a disability who is paid a special minimum wage?
c. Attach to this application productivity rating/evaluation forms for three currently employed workers with disabilities who are paid hourly rates (if you
employ workers with disabilities at special minimum wages on an SCA contract, one of the three employees for whom data is submitted must pertain
to an SCA service employee). Include all material relating to the evaluation which shows the worker’s individual productivity in proportion to the wage
and productivity of an experienced worker, who does not have disabilities, performing essentially the same type, quality and quantity of work in
the vicinity.
11. FOR RENEWAL APPLICATIONS ONLY — PIECE RATES
a. How many workers with disabilities employed under the terms of this certificate received special minimum wages and were paid piece rates during
the fiscal year cited in Block 8 above? (If the answer is 0, go on to question 12.)
b. Please provide the following information about the four largest current contracts on which workers with disabilities earning special minimum wages
are paid piece rates and attach supporting time studies or work measurements.
Description of Work
Prevailing Wage
Standard
Piece Rate
(e.g., Packaging, Shrink
Determined for This Job
Productivity
Paid to Workers
Wrapping, Labeling)
(Expressed in a Rate per Hour)
(Units/Hour)
(Rate per Unit)
(continued on next page)
Form WH-226
Rev. January 2008

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