Form Dlse 177 - Application For Sheltered Workshop License (Labor Code Section 1191.5) Page 2
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211. Disability Groups Employed:
Mental Illness
Visual Impairment
Hearing Impairment
Age Related
Alcoholism
Drug Addictions
Neuromuscular
General – No Primary Group
Developmental Disability Specify: ____________
Other Specify: __________________
12. Describe work measurement method and evaluation process. (Attach a separate sheets as necessary)
You must also attach copies of work measurement documentation evidencing justification for wage rate being requested (See General Information
and Instructions (DLSE 117-A) for instructions regarding required information/documentation)
CERTIFICATION
I certify that I have read this form and to the best of my knowledge and belief, all answers and information given in the application and attachments
and the representations set forth in support of this application to obtain or continue authorization to pay workers with disabilities at special minimum
wage rates are true. I further represent that the following terms and conditions exist (or will exist for initial applicants):
(a) workers employed (or who will be employed) under the authority of Labor Code §1191.5 have disabilities for the work to be performed;
(b) wage rates paid (or which will be paid) to workers with disabilities under the authority of Labor Code §1191.5 are commensurate with
those paid experienced workers, who do not have disabilities, in industry in the vicinity for essentially the same type, quality and quantity of
work;
(c) the operations are (or will be) in compliance with the applicable Industrial Welfare Commission Order, the California Labor Code and all
applicable State and Federal Law;
(d) records will be maintained as required by Section 7 of the Industrial Welfare Commission Orders and consistent with the requirements of
29 CFR 525 including documentation of disability, productivity, work measurements and prevailing wage surveys;
(e) a copy of the license shall be maintained at each location where individuals are employed;
(f) a copy of the DOL poster “Employee Rights for Workers with Disabilities Paid At Special Minimum Wages” shall be posted at each
location where individuals will be employed
(g) consistent with the requirements of DOL, a wage review must be completed at least once every six months and a prevailing wage survey
must be performed annually;
(h) consistent with the requirements of Cal/OSHA an Injury and Illness Prevention Program (IIPP) shall be maintained along with all
required Cal/OSHA documentation and reports; and
(i) written and oral advice of wage rate being paid has been provided to each worker and/or his/her guardian.
_________________________________________________________
Print Name
Title
Date
__________________________________________________________
Signature
FOR DLSE USE ONLY
DLSE 117 (1 1/08)
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