Department of Health and Social Services
Division of Public Assistance
ALASKA TEMPORARY ASSISTANCE PROGRAM
SUBSISTENCE - Community Work Experience Placement Agreement
Participant’s name: Village:DPA office address:
Nome Department of Labor & Workforce Development
Box 2110
215 E. Front Street
Nome, Alaska 99762 / Work site name and address:
Kawerak Native Employment Work Services
PO Box 948
Nome, AK 99762
Work site phone number:
Phone: (907) 443-4275
Toll Free: (855) 443-4275
/ Name of work site supervisor:
Kawerak Native Employment Work Services (KNEWS)
Start date: / End date: Open
List work site tasks assigned to the participant:
Various subsistence / Elder Care / Traditional Tribal activities
Number of hours per week:
Varies / Work schedule (days/times):
Varies
· Log all hours spent in Subsistence, Elder Care or Traditional Tribal activities on the log you have been provided by your case manager.
· At the end of the month turn this log into Kawerak Native Employment Works at the number listed above.
· In order to be countable as Work Activities you must be contributing to the good of your community.
· Please be prepared to have someone who can verify your hours upon request.
· Thank you for serving your community!
______
Participant Date
______
Caseworker (DPA or its representative) Date
The Alaska Department of Health and Social Services, Division of Public Assistance, complies with Title II of the Americans with Disabilities Act of 1990. This form is available in alternative communication format upon request. Please contact the Director’s Special Assistant at (907) 465-3349, TDD (907) 465-3347.
DPAWS Field Services Page 1 of 1 Nov 2015