Scsep forms north Carolina Program Operations Manual


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NameScsep forms north Carolina Program Operations Manual
A typeManual
SCSEP FORMS

1. North Carolina Program Operations Manual
2. Host Agency Handbook & Forms

(i) Host Agency Handbook

(ii) Required Forms for Host Agency File

a. File Checklist

b. Host Agency Application (to be renewed annually)

c. Host Agency Agreement & Orientation checklist

d. In-Kind Funding Statement

e. Training Plan

f. Annual Safety Monitoring Report
3. Participant Handbook and Forms

(i) Participant Handbook

(ii) Required Forms for the Participant’s Record
Section A: Eligibility/Selection

A1. Participant Form

A2. Confidential Statement of Income (with supporting documentation),

completed annually with intake/recertification

A3. Self-Attestation Forms and Number

Homeless P8

Not Employed P13

Zero Income P14

Limited English Proficiency P22

Low Literacy Skills P24

Veteran/Eligible Spouse P25

At risk of homelessness P27

WIA Title 1 P29

Low Employment Prospects P30

Persistent Unemployment P54

A4. Third-Party Attestation Forms and Number

Homeless P8

Number in Family P11

Employed Prior to Participation P13

Zero Income P14

Limited English Proficiency P22

Low Literacy Skills P24

At risk homelessness P27

A5. Employment Eligibility Verification Form 1-9

A6. Physical Exam Offer Waiver

A7. Disclosure of UI Benefits

A8. WIA Referral Form

Section B. Assessment/Assignment

B1. Assignment Form

B2. Participant Enrollment Agreement

B3. Participant Needs Assessment

B4. Training Plan (includes work schedule)

B5. Community Service Assignment Form
Section C: Orientation/IEP

C1. Orientation Checklist

C2. Individual Employment Plan (IEP) & IEP Progress Review
Section D: Recertifications

D1. Income computation and Eligibility Determination

• Physical Exam Offer

D2. Recertification Form/Individual Employment Plan

D3. Self- Attestation Form

• Family Income Recert Form P45

D4. Third-Party Attestation Form

• Number in Family Recert Form P44
Section E: Exits and Terminations

E1. Exit Form (Once or if the participant exit the program)

E2. Transitional IEP

E3. Self-Attestation Form Exclusion

• Exclusion after exit E9a

• Other reason for exit E6

E4. Third-Party Attestation form Exclusion

• Exclusion after exit E9

• Other reason for exit E6
Section F: Follow Ups

F1. Unsubsidized Employment Form (if placed)

F2. Self-Attestation Form Wages U28c, U29c, U29e, U30c

F3. Third-Party Attestation Form Wages U28c, U29c, U29e, U30c
Section G: Misc. Other

G1. Case Notes and Activities

G2. Participant Evaluation(s) (a minimum of one annually)

G3. Host Site Supervisor Evaluation(s) (a minimum of one annually)

G4. Request for Supportive Services (if any)

G5. Right of Return

G6. Time Sheet (contact State Coordinator)

G7. Approved Break in Participation
4. Optional Forms

(i) Participant Training Data

(ii) Sample Termination Letter

(iii) Sample Termination Letter-For Cause

(iv) Sample Employer Follow-Up Letter for Wage Information
5. TEGL

1. 05-03

2. 17-13

3. 26-13

4. 10-09

5. 12-06

6. 12-06 Attachment 1

7. 12-06 Attachment 2

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