HOST AGENCY WORKSITE VISIT CHECKLIST

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					                              Host Agency Monitoring Checklist

Host agency training site:                                                   Training site ID:

Supervisor name:                                                             Supervisor ID:

State:                              County:

Date:                                         Type of visit:    Initial     Annual       Follow Up

                                                                          Follow-
                                                                            up
  Monitoring Checklist                                 Yes      No        Needed              Comments

  Does the training site have a copy of the
  signed host agency (HA) agreement?
  Date of current HA agreement on file at
  site:____________________

  Has the participant’s HA supervisor been
  changed since the previous monitoring? (If
  yes, provide details in Comments section)

  Does the training site have a copy of the most
  current participant IEP/training plan?

  Has there been any change in participant
  duties since last monitoring visit? (If yes,
  provide details; update IEP if required.)

  Did the supervisor assist with the development
  of the participant’s training plan?

  Does/can training site offer training for in-
  demand local jobs? (If yes, describe in
  Comments section.)

  Is the training being provided to the participant
  consistent with the participant’s IEP/training
  plan?

  Does the HA supervisor evaluate participant
  progress? (If yes, note in Comments section if
  it meets the IEP quarterly requirement.)

  Is the HA supervisor concerned with the
  participant’s ability to perform the assignment?
  (If yes, describe in Comments)




                                                       Page 1 of 4
                                                                    Follow-
                                                                      up
Monitoring Checklist                                  Yes      No   Needed    Comments

Is direct supervision consistently provided to
the participant?

Are supervisory hours recorded on the
timesheet? If yes, how many hours on
average? _________________

What source of funds is used to pay the
supervisor’s wages?
   Federal funds    Non federal      Both

What type of agency is this host agency?
  Fed Govt.     State Govt.
  Local Govt.    501(c)3

Does the supervisor understand the
importance of considering participants for
employment?

Are there possibilities for participant to be
hired by the training site? (If yes, describe)

If participant is nearing or in durational limit
year, is HA supervisor aware of EW’s DL
policy?

If in durational limit (DL) year, can training site
provide additional training, transitional support,
or other services to the participant? (If yes,
describe)

Does the training site maintain the participant’s
original signed and dated timesheets in a
confidential file?

Upon review of timesheets, does review show
the HA supervisor signed the participant’s
timesheet each pay period?

Does the HA supervisor fax/email the
timesheets (rather than the participant) to the
customer service center?

Does the training site supplement the
participant’s hours of work and/or hourly
wage? (If yes, explain under Comments)




                                                      Page 2 of 4
                                                                  Follow-up
 Monitoring Checklist                               Yes     No     Needed      Comments

 Has HA supervisor allowed participant to
 volunteer time at the HA in addition to SCSEP-
 paid time? (If yes, describe in Comments)

 Does the HA supervisor allow the participant
 to bank hours? (If yes, describe in Comments)

 Does the HA supervisor allow the participant
 to make up time missed due to illness and
 agency holiday closings?

 Does the HA supervisor contact EW when the
 participant is absent from the assignment for
 more than four days? (If no, add Comments)

 Does the HA supervisor have access to the
 Internet/email? If yes, verify email address on
 file: email:_________________________

 If not already receiving notification, would HA
 supervisor like to have an email notification of
 receipt of participant timesheet?

 Is there any information that the HA supervisor
 thinks EW should be made aware? (If yes,
 note in Comments section)

 Review the participant schedule – is schedule
 current?

 Does training site pay workers’ compensation
 costs for participant(s)?

 Are any HA staff related to the participant(s)?
 (If yes, provide details in Comments)

 Is the participant performing any duties that
 used to be done by a current or former staff
 member? (If yes, detail in Comments; follow
 up if maintenance of effort violation)

 Has training site required or allowed the
 participant to engage in political activities
 during SCSEP-paid hours? (If yes, describe in
 Comments; follow up if Hatch Act violation)

 Does the HA supervisor have any suggestions
 for improvement? (If yes, note in Comments)


ETC Signature                                                           Date

ETC Printed Name

                                                    Page 3 of 4
Form Instructions:

       This form replaces any previous host agency monitoring form used by staff. (It does not replace
        the Safety Monitoring Checklist, HASR, HA Agreement, or other HA forms. These must continue
        to be used.)
       Checklist must be completed by an ETC or other EW staff member. The form may not be
        completed by either a participant assistant or a host agency staff.
       Submit to supervisor upon completion.
       The form is first completed at least three months after participant has been placed at host agency
        but no later than end of first year of assignment. The form is completed at least annually
        thereafter (more often if problems are identified).
       Checklist is a guide to be used during discussions with host agency supervisor or other appropriate
        HA staff. Some questions may be answered after reviewing specific documentation, such as
        looking at the most current HA agreement the HA supervisor has or at the HA participant
        timesheet file.
       ETC must provide a response to all questions, fully completing form.
       If supervisor supervises multiple participants, ETC responses must take this into consideration.
        For example, responses to questions on participant evaluation or timesheets would have to cover
        all participants supervised, not just one.
       Problems identified as a result of monitoring must be followed up in writing with host agency
        (copy to EW state office) within two weeks of monitoring visit. Additional on-site monitoring of
        the problem areas may be required (ETC may need to consult with supervisor to make this
        determination).
       Relevant information uncovered as a result of host agency monitoring, especially information
        concerning participant progress, training, or job readiness, should be incorporated into the
        participant’s IEP and/or case notes.




9/10/2012


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