Form Sna-1023a - Agreement For Work Experience And Community Service Activities
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
SNA-1023A FORFF (7-17)
Workforce Administration
Supplemental Nutrition Assistance Employment and Training (SNA E&T) Program
AGREEMENT FOR WORK EXPERIENCE AND
COMMUNITY SERVICE ACTIVITIES
1. THE AGREEMENT
This Agreement is entered into between the Arizona Department of Economic Security (DES), hereafter called the Sponsor and
NAME OF BUSINESS OR AGENCY
TYPE OF BUSINESS
hereafter referred to as the Provider Agency, to provide work-related activities so that the DES Supplemental Nutrition Assistance
Employment and Training (SNA E&T) Program participants, who are assigned to a work experience or community service activity, can
learn vocational skills and gain work experience.
2. WORK EXPERIENCE AND COMMUNITY SERVICE SPECIFICATIONS
This Provider Agency agrees to the following specifications:
A.
PRIMARY POSITIONS AND DUTIES (Attach list if more space is needed)
SPECIFIC EQUIPMENT TO BE USED
B.
PHYSICAL REQUIREMENTS AND/OR SPECIAL OCCUPATIONAL REQUIREMENTS
C.
NAME AND TITLE OF SUPERVISOR(S)
3. WORK EXPERIENCE AND COMMUNITY SERVICE PROVIDER’S AGREEMENT
The Provider Agency further agrees to:
A. Provide a work experience or community service assignment that will not fill an established vacant position including partial
displacement such as a reduction in the hours of non-overtime work, wages or employment benefits or replace personnel who have
been laid off or terminated by the Provider or when the Provider has otherwise reduced its workforce.
B. Maintain records and prepare reports on the individual work experience or community service trainee(s) as prescribed by the Sponsor.
C. Observe and comply with applicable safety and health standards and the labor laws of Arizona and the federal government.
D. Maintain sufficient general liability insurance for tort claims protection.
E. Maintain sufficient workers compensation and employers’ liability in accordance with all state and federal laws and regulations.
F.
Allow the Sponsor and/or duly authorized representatives to visit the premises, observe work conditions and activities and interview
the work experience or community service trainee(s).
4. SPONSOR’S AGREEMENT
The Sponsor agrees to:
A. Supply the Provider Agency with the required forms and procedures for maintaining work experience or community service trainee(s)
records and instructions on required reporting information.
B. Provide supportive services that may be required by the work experience or community service trainee(s).
C. Provide monetary transportation related expense payments to eligible work experience or community service trainee(s).
5. ADDITIONAL DECLARATIONS
Work experience and community service trainee(s) are not employees of the Provider Agency or of DES, but are recipients of
Supplemental Nutrition Assistance Program benefits and are not compensated at a salary rate for the work done. Work experience
and community service trainee(s) may be covered by the Arizona Health Care Cost Containment System (AHCCCS) medical program.
This Agreement may be terminated by either party by giving written notice to the other party not less than five (5) working days before
the intended termination date and is subject to A.R.S. § 38-511 regarding conflict of interest.
PROVIDER AGENCY’S NAME (Print legibly)
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
PHONE NUMBER
AUTHORIZED REPRESENTATIVE’S SIGNATURE
DATE
NAME AND TITLE (Print legibly)
Arizona DES/WA/SNA E&T Program
SPONSOR:
P.O. BOX 6123 – Mail Drop
PHOENIX, AZ 85005-6123
OFFICE ADDRESS:
PHONE NUMBER
AUTHORIZED REPRESENTATIVE’S SIGNATURE
DATE
NAME AND TITLE (Print legibly)
See reverse for EOE/ADA/LEP/GINA disclosures
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