(REVISED 8/6/18)

WIOA YOUTH INCENTIVE REQUEST POLICY

INCENTIVE REQUEST

Submit to RochesterWorks! Bibianna Silvera-Portacio, Youth Program Specialist

Date: ______

Enrolled WIOAYouth Name, NY#,and Request# (i.e. 1st, 2nd, 3rd):

______

Requested: Navigator Name/Organization:______

Navigator Checklist: Verify completed:

_____ Individual Services Strategy (ISS) in hard file

_____ Dually signed Objectives and Services History (once a quarter: hard file)

_____ WIOA Youth Incentive Request

_____ 1st: Customer Detail Page (Data Entry)

_____2nd: Comp Assess Page (Data Entry)

_____ 3rd: Services Page(Data Entry)

  1. Achievement Objective (active status youth, only)
  2. Service/Element (active status youth or youth in follow up status)
  3. Comment (SENSE Model) (active status youth or youth in follow up status)

In recognition of (Maximum total incentive disbursement per youth is $250):

  • Initial TABE Assessment $10
  • Completion: Prescribed Work Readiness Series (workshops &/or activities) $25
  • Placement Employment/Education (2nd Q after exit) $50
  • Placement Employment/Education (4th Q after exit) $50
  • Credential Attainment Post-Secondary Credential, HS or HSE Diploma (4th Q after exit) $50
  • Measurable Skills Gain (EFL gain/PSE Report Card/Training Milestone/Skills Progression)$50
  • Post-Test TABE $25
  • NWRC Certification, or WorkKeys Certification (Bronze, Silver, Gold, or Platinum) $25
  • Completion: Youth Employment Program (YEP)/ITA/OJT (90% + attendance/positive reports) $25
  • Other$25 ______(Directly tied to workforce training activities, work experiences, outcomes.)

Gift card availability and fill in quantity requested:

  • McDonald’s ($10) ___ Quantity
  • Wegmans ($10) ___ Quantity
  • Goodwill ($25) ___ Quantity
  • McDonald’s ($25) ___ Quantity
  • Speedway gas card ($25) ___ Quantity
  • Subway ($25) ___ Quantity
  • Wal-Mart ($25) ___ Quantity
  • Wegmans ($25) ___ Quantity

ROCHESTERWORKS USE ONLY BELOW:

Processed/Verified for completeness:(signature and date): ______

Approved (signature and date): ______

Recordlast 5 digits of gift card(s).______

INCENTIVE RECEIPT

Original receipt returned within 5 business days to RochesterWorks!

Cassilda Campbell, Youth System Assistant

Copy in youth’s hard file, (Maximum total incentive disbursement per youth is $250):

Date: ______

NY# (must be WIOA enrolled youth in OSOS): ______

Today I,(Youth -Print Name) ______received the following gift card(s) or other:

Circle/Check gift card(s) and fill in quantity:

  • McDonald’s ($10) ___ Quantity
  • Wegmans ($10) ___ Quantity
  • Goodwill ($25) ___ Quantity
  • McDonald’s ($25)___ Quantity
  • Speedway gas card ($25) ___ Quantity
  • Subway ($25)___ Quantity
  • Wal-Mart ($25) ___ Quantity
  • Wegmans ($25) ___ Quantity
  • Other ______Quantity

Record last five number digits of gift card(s).For Wal-Mart gift cards, notate the last 5 numbers of the gift card that begin with “SC…..53484” For Goodwill gift cards, notate the last 5 numbers of the gift card before the BID and the CVV numbers.

______

By signing below, I take full responsibility for safeguarding the gift card(s) issued to me today. Lost or stolen gift card(s)/ other incentive disbursement will not be replaced.

Youth Signature: ______

Requested completed by: Print Navigator Name/Organization:______

Navigator Signature: ______

ROCHESTERWORKS USE ONLY BELOW:

Original Receipt Received: ______

RochesterWorks! is an equal opportunity program. Auxiliary aids and services are available upon request to individuals with disabilities.

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