City of Sacramento
City Council - 2PM Report
915 I Street Sacramento, CA 95814
www.cityofsacramento.org
File ID: 2022-01254 3/28/2023 Consent Item 9.
Agreement: County of Sacramento, Community Work Experience Program (CWEX) File ID: 2022-01254
Location: Citywide
Recommendation: Pass a Motion authorizing the City Manager or the City Manager’sdesignee to execute an agreement with the County of Sacramento to allow the City to provide work experience opportunities to eligible CWEX participants.
Contact: Randy Singh, Volunteer Engagement Specialist, 916-808-4056, [email protected], Tiana Jordan, Administrative Analyst, 916-808-2677, Office of Innovation and Economic Development Department
Presenter: None
Attachments:
1-Description/Analysis
2-CWEX Agreement
3-Community Work Experience Brochure
4-Community Work Experience Work Order Form
5-Community Work Experience Employer Handbook
Description/Analysis
Issue Detail: The California Work Opportunity and Responsibility to Kids (CalWORKs) program is a time-limited program that provides financial assistance to eligible needy families. This is California's version of the Federal Temporary Assistance to Needy Families program. CWEX is a non-salaried Welfare-to-Work activity that provides CalWORKs recipients with the opportunity to acquire the skills, experience, training, knowledge, and work habits necessary to obtain employment.
The purpose of CWEX is to provide CalWORKS participants with on-the-job training to improve skills and provide current workplace experience. The goal is for the individual to gain the skills that will lead to unsubsidized employment. Participants also meet CalWORKs Welfare- to- Work requirements through their CWEX placements. CWEX participants are placed in public or private agencies to
File ID: 2022-01254 3/28/2023 Consent Item 9.
update work skills and gain valuable experience. Placements also deliver valuable services to community agencies.
The City and the County of Sacramento entered into a CWEX agreement in 1999. That agreement is still in effect today and will remain in effect until it is terminated by the parties. The County would like to update the terms of the CWEX agreement by entering into a new CWEX agreement to provide work experience opportunities for CalWORKS participants. By entering into the new CWEX agreement, the parties would terminate the 1999 CWEX agreement.
Policy Considerations: Continued participation in on-the job training is consistent with the City’s strategic plan to enhance livability.
Economic Impacts: None.
Environmental Considerations: This report concerns administrative activities that will not have any significant effect on the environment and that do not constitute a “project,” as defined by CEQA [CEQA Guidelines Sections 15061(b)(3); 15378(b)(2)].
Sustainability: Not applicable.
Commission/Committee Action: None.
Rationale for Recommendation: The County would like to update the terms of the 1999 CWEX agreement by entering into a new five-year CWEX agreement with the City.
Through this agreement, CWEX would work with the City’s Volunteer Coordinator to arrange on-the- job training opportunities for CWEX participants. The City’s Volunteer Coordinator would work with City departments to assign CWEX participants to work experience that most benefits the participants.
City department staff would support the work experience and on-the-job training experience for the CWEX participant by orienting the participant to the workplace, provide training and work experience, and to complete and submit both a monthly time sheet and periodic evaluations to CWEX. The City’s Volunteer Coordinator will support ongoing communication between the City and CWEX staff.
Financial Considerations: There is no cost to the City to participate in the CWEX program.
Local Business Enterprise (LBE): Not applicable.
Background: The County changed the CWEX agreement from an open-ended agreement to a five- year term.
File ID: 2022-01254 3/28/2023 Consent Item 9.
The County has also changed the CWEX agreements to ensure accuracy, and to keep employer records up to date. This allows for more interaction between the parties to address any needs or ongoing participation questions. More importantly, the change will improve communication because staff will meet to make updates and any desired changes, All employers that currently have signed CWEX agreements, including the City, will need to sign a new CWEX agreement. The changes will not affect the service that County staff has provided to the City and will not result in moving CWEX participants.
Community Work
Experience Program
Sacramento County
Department of Human Assistance
Community Work Experience Program (CWEX)
(916) 875-3330
Sacramento County Board of
Supervisors:
District 1 – Phil Serna
District 2 – Patrick Kennedy
District 3 – Rich Desmond
District 4 – Sue Frost
District 5 – Don Nottoli
County Executive Officer
Ann Edwards
Director
Ethan Dye
How can you help?
CWEX participants are encouraged to seek paid employment and your agency may decide to hire a qualified participant. If no suitable openings occur, and the participant’s performance has been satisfactory, we request that you provide a letter of reference for the participant’s job search.
What paperwork is involved?
Each agency will initially complete a worksite agreement and job order to enroll in the CWEX program. A time sheet and evaluation must be submitted monthly for each participant.
Will agency supervisors be able to participate in the
selection of CWEX participants?
Yes. CWEX staff will screen and refer prospective participants. Your agency will interview and select the candidate who best fits your needs. CWEX wants the agency and participant to be satisfied and comfortable with their assignment.
What is CWEX?
CWEX is a non-salaried Welfare-to-Work activity which provides CalWORKs recipients with the opportunity to acquire the skills, experience, training, knowledge and work habits necessary to obtain employment.
What is CalWORKs?
The California Work Opportunity and Responsibility to Kids (CalWORKs) program is a time-limited program that provides financial assistance to eligible needy families. This is California's version of the Federal Temporary Assistance to Needy Families program.
What are CWEX placements?
CWEX participants are placed in public or private agencies to update work skills and gain valuable experience. Placements also deliver valuable services to community agencies.
What is the purpose of CWEX placements?
The purpose is to provide CWEX participants with on the job training to improve skills and provide current workplace experience. The goal is for the individual to gain the skills that will lead to unsubsidized employment. Participants also meet CalWORKs Welfare to Work requirements through their CWEX placements.
How long does a CWEX placement last?
A CWEX placement is intended to be short term and is determined by each participant’s situation.
How many hours may a CWEX participant work?
Hours vary according to the participant’s Welfare to Work Plan. The average is from 20 to 30 hours a week.
Are there any wages or costs involved?
No. Participants will continue to receive their monthly CalWORKs grants while in training. In addition, CalWORKs will pay their child care and transportation costs.
Who is a typical CWEX participant?
Participants are individuals with diverse backgrounds and work experience. Some may have marketable skills but are currently out of work. Others may need to update or acquire new skills to succeed in today’s workforce. This placement will give them an opportunity to obtain practical work experience.
Participants placed in your agency will meet your established minimum requirements. Participants are placed in agencies in their own neighborhood whenever possible.
Are there any restrictions on the types of work CWEX
participants may perform in their placement?
Employers must be in compliance with federal and state workplace requirements.
What about Worker’s Compensation?
The cost of Worker’s Compensation will be paid by the state.
Are there limits on the number of CWEX participants who may be placed with a particular agency?
No. However, individual supervisors should limit the number of participants to insure proper supervision, evaluation and training.
What is expected of participating agencies?
It is expected that CWEX participants will be oriented to their work site and that the agency will provide training and mentoring. It will also be necessary for the agency to complete and submit both a monthly time sheet and periodic evaluations. Ongoing
communication between the agency and CWEX staff is essential.
Sacramento County Department of Human Assistance
1725 28th Street
Sacramento, California 95816
COMMUNITY WORK EXPERIENCE PROGRAM (CWEX)
Work Site Participant Order Form
Agency Name:
Address:
Job Site Address: Zip:
City: Email:
Contact Person:
Phone: Fax: Email:
Job Site Supervisor:
Cell Phone: Desk Phone: Email:
CWEX Position Title: Shift Required: Days Nights Swing Variable Weekends
Number of Positions Requested: Minimum Hours/Week: Maximum Hours/Week:
Require Background Check Require Finger Print
Require TB Test Require Drug Testing
Job Description (use second page if needed):
Skills Required: General Computer Use Typing Phones Basic Math Data Entry Written Communication Verbal Communication
Is experience a requirement? Yes No If yes, this may limit our ability to fill your need.
Equipment Needed (use second page if needed):
Employer Trainings Offered: Yes No On the job training If yes explain areas of training:
HS Diploma/GED Required: Yes No
Are Limited English Placements Accepted? Yes No
If yes, specify language:
Special Physical Requirements: Extreme Temps Heavy Lifting Lengthy Standing Outdoor Work Potentially Hazardous Situations
Remarks:
Other requirements (no beards, no piercings, etc.)
Authorized and Approved by: Date:
Return to: Sacramento County Department of Human Assistance – Attn: CWEX 1725 28th Street
Sacramento, CA 95816
REV June 2019
Sacramento County
Department of Human
Assistance
C W E X
Community Work
Experience Program
Employer Handbook
1 TABLE OF CONTENTS
Welcome To the Community Work Experience Program (CWEX) ............................. 2 What Is CWEX? ....................................................................................................... 3 Who are the participants? ..................................................................................... 3 Who will oversee the CWEX plan in the community? ........................................... 3 What job services will be offered? ........................................................................ 3 What supportive services will be offered? ............................................................ 3 What happens if CWEX participants do not participate? ...................................... 3 Your Obligations As A CWEX Worksite Sponsor ..................................................... 4 State Regulations .................................................................................................... 5 Ongoing Job Search ................................................................................................ 5 Within Your Agency .............................................................................................. 6 Within DHA ........................................................................................................... 6 Ongoing Operations ................................................................................................. 7 Getting Started ..................................................................................................... 7 Attendance Record ............................................................................................... 7 Absences or Tardiness ......................................................................................... 7 Evaluations ........................................................................................................... 8 Site Visits/DHA Contacts ......................................................................................... 9 Fingerprinting, Background Checks & Drug Testing .............................................. 10 Steps To Follow When An Injury Occurs ........................................................ 101-12 Steps to follow when there is an incident ............................................................... 13 Appendix ................................................................................................................ 14
2 WELCOME TO T HE COMMUNITY WORK EXPERIENCE
PROGRAM (CWEX)
Thank you for your participation in our CWEX program!
As a CWEX worksite supervisor, you will have a major role in a program designed to assist Welfare to Work individuals entering the world of employment. Your participation will provide them with the opportunity to obtain work skills and real work experience.
The goals of the program are to:
• Provide current work experience,
• Help participants update their work skills,
• Provide an opportunity for participants to acquire marketable job skills, • Offer supervised work experience in a realistic work setting, • Place participants in worksites appropriate to their interests, • Increase the employability of our participants,
• Provide opportunities to develop good work habits in a supportive environment, • And, ultimately, gain enough experience to become employed This handbook is design to assist you with questions that will arise as you work with CWEX participants. Please read it and keep it handy for future reference.
It is our intent to facilitate quality work and meaningful relationships between you and the participants. In addition, we want to provide you with the best supportive services possible.
Please let us know how we can help you in your supervisory role. We want to work together to make your experience, as well as the participant’s experience, a success.
Thank you again for your participation!
Throughout this handbook, you will find references to necessary forms that are part of the CWEX process. Your CWEX Coordinator provides these forms to you, and examples of these forms with important highlights will be included in the Appendix at the end of this handbook.
3 WHAT IS CWEX?
• The Community Work Experience (CWEX) program is the Sacramento County version of the State Work Experience/Community Service program.
• CWEX is a non-salaried work experience with public or private employers.
• CWEX assignments provide the participant with real life work experience, a reference for future employment, and new job skills.
• A CWEX placement is intended to be short term (up to 6 months).
• CWEX assignment hours are based upon their grant amount. Average hours are 20 per week but can range from 10 to 35 hours.
• Participants assigned to CWEX are expected to continue to seek employment and should continue to utilize job search services throughout their assignment.
• CWEX assignments are to be reviewed periodically to assure that the assignment continues to conform to the contract and that it is likely to lead the client to gainful employment.
Who are the participants?
Participants include all CalWORKs adults who are Welfare to Work participants.
Who will oversee the CWEX plan in the community?
The Sacramento County Department of Human Assistance is responsible for development and administration of CWEX. CWEX must be responsive to the local labor market conditions and use existing community resources whenever possible.
What job services will be offered?
During their assignment, DHA will offer support to the participant and the employer to assure successful outcomes.
What supportive services will be offered?
Welfare to Work participants are eligible for transportation and child care.
Payment for ancillary costs such as tools and special clothing needed for participation can be provided, although the items requested must be a requirement of all employees.
What happens if CWEX participants do not participate?
Refusal to participate, without good cause, can lead to discontinuance of cash aid. Your CWEX Coordinator will notify you when/if a placement ends. 4 YOUR OBLIGATION S AS A CWEX WORKSITE SPONSOR
The CWEX participants at your agency will be counting on you to:
• Introduce them to other employees or trainees.
• Provide them with an overview of the agency.
• Provide an orientation of what is expected on the job.
The participant will have the same needs as any other new employee who has come to work under your supervision. Keep in mind that some of these men and women, although desiring to work and motivated to succeed, may not have been in a traditional worksite in many months or even years. They may need some “transition time” before they are learning and working up to full speed.
The following steps may serve as a useful guide:
1. ORIENT the participant to the worksite, the work to be performed and the expected behavior on the job.
2. DEVELOP A TRAINING PROGRAM to help the participants gain the skills and abilities to perform the specific task and to acquire desirable work behavior.
3. PLAN AND SCHEDULE tasks so that desired objectives can be reached and so the participant is kept busy. Increasing the participant’s responsibilities over time will serve to enhance his/her work experience.
4. ORGANIZE staff, job tasks, and materials so that specific job goals can be achieved.
5. MOTIVATE THE PARTICIPANT toward good work behavior and performance. Pass on the knowledge and the experience that you have acquired during your employment.
6. EVALUATE the participant’s behavior and performance. This can be done during your regular meetings with the participant, as well as when opportunities arise on the job.
7. SOLVING PROBLEMS AS THEY ARISE will help the participant learn needed skills.
Staying current with your expectations and addressing problems as soon as they come up will result in a positive outcome for both of you.
8. CONGRATULATE YOURSELF! Supervision and training are big jobs and to be successful at them you must have well-developed people skills. Your commitment can make the difference between public assistance and gainful employment for your participants.
5 STATE REGULATIONS
A CWEX position cannot result in any of the following:
1. Displacement of current employees, including overtime currently worked by those employees.
2. Filling of established unfilled positions, unless the positions are unfunded in a public agency budget.
3. Filling of positions, which would otherwise be promotional opportunities for current employees.
4. Filling of a position prior to compliance with applicable personnel procedures or provisions of collective bargaining agreements.
5. Filling of a position created by termination, lay-off, or reduction in workforce.
6. Filling of a work assignment customarily performed by a worker in a job classification within a recognized collective bargaining unit in that specific worksite, or the filling of a work assignment in any bargaining unit in which funded positions are vacant or in which regular employees are on layoffs.
7. A strike, lockout, or other bona fide labor dispute, or violation of any existing collective bargaining agreement between employees and employers.
As a worksite supervisor, you are in a unique position to educate your employees and fellow colleagues about the goals of CWEX. Employees have concerns about job displacement or the kind of issues that are addressed in the above section. By following these regulations, existing staff will know that participants are there only to enhance their job skills.
Form SC 246.211
WTW Notice to Employees
must be posted
See Attachment 1
6 ONGOING JOB SEARCH
Within Your Agency
Worksite supervisors should encourage qualified CWEX participants to compete for job openings occurring within your worksite.
CWEX participants assigned to your agency should be allowed to participate in examinations for which that individual is qualified.
Within DHA
Participants are expected to continue actively seeking employment through:
• Meet with a Job Developer
• Attend Job Talks
• Job interviews
• Hiring Job Fairs
Participants should give you prior notice of these events, and return to work to complete their shift if possible.
It is the goal of CWEX to help participants acquire the skills and experience that will allow them to be in a position to compete for job openings.
7 ONGOING OPERATIONS
Getting Started
After you have been contacted by a Bureau CWEX Coordinator (BCC) to schedule an interview with the prospective participant, you will receive the Referral to Community Work Experience (CWEX) Program Worksite form (see Attachment 2). This form will serve as a letter of introduction for the participant, and information for you, the employer, regarding how many hours the participant is required to complete. After the interview is completed, and the participant is selected for your site, you will use this form to report the participant’s start date and work schedule.
Once the form is completed, please email to [email protected]
Attendance Record
• You will receive the first CWEX Time & Attendance Record (SC 246.75) (see Attachment 3) at the start of the placement.
• Assure that the hours claimed are adequately documented. • T he time sheet has blank spaces for explanation of any absences. • C omplete and sign the timesheet in ink.
• You may want to keep a copy for your files.
The time sheet hours should be recorded daily and completed time sheets submitted monthly (or when placement ends) and email to [email protected] by the 5th of the following month.
Absences or Tardiness
Please notify us of any excessive absences or attendance problems as they occur.
• The criteria for successful completion of a CWEX assignment include regular attendance and satisfactory progress.
• Positive work habits are a major goal of CWEX.
• The criteria for evaluating tardiness and absence during CWEX will be based on normal attendance standards for your work site.
• Please explain to the CWEX participant your agency’s procedure for reporting tardiness or absence. It is the CWEX participant’s responsibility to inform you of any planned absence in advance.
• T he worksite supervisor should contact the CWEX program staff about any excessive and/or unexcused absences.
• CWEX staff will need to contact the participant to determine the reason.
• If there will be any change in the participant’s CWEX status, you will be notified.
8 Evaluations
As a supervisor, you are asked to observe and evaluate the competence, behavior, and performance of each of the participants working for you. The major purpose of the evaluation is to help the participant improve his or her performance and job skills.
Participants want to know what is expected of them, how well they are meeting these expectations, and how they can improve. It is important that evaluations be completed at regular intervals, and discussed with the participant.
Participant Progress Review Evaluations help to:
1. Let participants know what is expected and how well these expectations are being met.
2. Determine training needs.
3. Identify participants who need more instruction.
4. Plan the work schedule according to the ability of each participant.
5. Maximize the participant’s full potential.
6. Demonstrate to participants that you have an interest in helping them improve their performance.
7. Assure participants that their work is recognized and appreciated.
Written participant performance evaluations are required for each CWEX participant: The Participant Progress Review form (SC 246.86, Attachment 4) will be provided at the time of placement.
This form should be completed at the end of each month and emailed to DHA-CWEX-Site-
[email protected], al ong with the client’s time and attendance record.
If you have any questions about it, please ask the CWEX staff.
9 SITE VISITS/ DHA C ONTACTS
Smooth operation of CWEX depends on good communication between CWEX staff, participants, and worksite supervisors. In order to facilitate this process as much as possible, CWEX staff members are ready to answer your questions and offer support when you need it.
The Bureau CWEX Coordinator will:
• Assist in providing guidance to participants and the worksite supervisor.
• Follow-up on each participant’s placement, including job performance, personal adjustment, etc.
• Review monthly attendance reports and evaluations.
• Serve as your immediate contact person to resolve any difficulties that may arise at the worksite.
The Area CWEX Coordinator will:
• Monitor assigned area sites' compliance with terms of the Agreement.
• Maintain a list of all sites and openings in the geographic area.
• Intervene when problems arise.
The CWEX Supervisor will:
• Facilitate communication between the site and the department.
• Maintain a master list of all sites and openings.
• Oversee the CWEX operation in the county.
To ensure smooth operation of this program, please contact the CWEX staff in the event of an accident, excessive tardiness, absence, or any concerns with a participant.
10 FINGERPRINTING, BACKGROUND CHECKS & DRUG TESTING
Sacramento County will provide fingerprinting services and pay for criminal background checks when they are required for CWEX participants. The actual submission of the LIVE SCAN form and the request for a criminal background check must be submitted through the worksite.
DHA staff will provide the Sacramento County billing code the applicant’s information, and Request for Live Scan Service form (BCII 8016, Attachment 5). You can find a fillable PDF of this form at https://oag.ca.gov/sites/all/files/agweb/pdfs/fingerprints/forms/BCIA_8016.pdf.
Please see Attachment 5 in appendix for important billing information.
The Department of Justice (DOJ) will complete the background check. A participant cannot be assigned to the site until the background check has cleared.
When the results are received by the worksite from the DOJ, the worksite will contact the Bureau CWEX Coordinator and inform them of the results. (NOTE: DOJ will not notify CWEX. They will notify the worksite).
STEP ACTION WHO
1 Provide billing code, applicant’s information and Request for Live Scan Service form (BCII 8016) to employer
DHA
2 Complete Request for Live Scan form and give to CWEX Volunteer Employer 3 Take Request for Live Scan form to authorized Live Scan agency, and have fingerprints run
CWEX
Volunteer
4 Complete background check and provide results to employer DOJ 5 Inform DHA and employee of DOJ’s results Employer
NOTE: If your organization/agency prefers to conduct fingerprint/background checks through your own internal process, the County will not pay for these checks and your agency is still required to notify our CWEX staff whether or not the client passed or failed said checks Sacramento County Department of Human Assistance (DHA) does not provide drug testing for CWEX participants. If drug testing is required, it is the responsibility of the CWEX worksite Sacramento County can only pay for background check services if the correct paperwork with the Sac County billing code # 110361-CWEX-DHA is submitted.
11 STEPS TO FOLLOW WHEN AN INJURY OCCURS
Information/Instructions for CalWORKs/Welfare-to-Work Workers’ Compensation
Background Information:
CalWORKs/Welfare-to-Work CWEX participants who are assigned to either Work Experience or Community Service positions are covered by Workers’ Compensation insurance paid by the California Department of Social Services (CDSS). There is no cost to the CWEX work site.
CDSS contracts with Intercare as the administrator of Workers’ Compensation benefits for CalWORKs/ Welfare-to-Work CWEX participants.
If a CWEX participant is injured while participating in a Work Experience assignment, the site supervisor should:
If Then
No treatment is required Provide first aid and follow appropriate reporting procedure
Minor injury Take or direct the injured participant to appropriate medical care and follow appropriate reporting procedure Serious injury, illness, or death Call an ambulance if appropriate and follow appropriate reporting procedure
In the event of an injury, the worksite supervisor must contact the county immediately to report the incident. The CWEX Supervisor could be reach at (916) 874-0945 or at (916) 875- 3330 (Clerical and ask for CWEX ACC (Area CWEX Coordinator) assistance).
1. After the work site Supervisor investigates the circumstances of the injury, he or she must provide the injured participant an Employee Claim form (DWC-1, Attachment 7) within one (1) working day of the date of the knowledge of the injury. After the participant completes the “employee” section of the form and returns it, the site supervisor must:
a. Complete the "employer" section of the DWC-1 form, scan and E-mail the form to [email protected] or fax the originals within 24 hours.
Note: If the employee cannot sign the DCW-1 form, their spouse can sign it for them b. Provide a copy to the participant
PLEASE NOTE: If a participant reports any injury, whether or not it require a workers' compensation claim, please complete the SUPERVISORS REPORT OF ILLNESS/INJURY and keep a copy for your records, then fax (916-875-3302), mail, or scan and email the original to:
CWEX SUPERVISOR
[email protected]
12 2. The work site Supervisor must also complete an Employer’s Report of Occupational Injury or Illness form, California 5020 (Attachment 7), and the Supervisor’s Report of Illness and Injury (Attachment 8) within 24 hours of the knowledge of the injury:
a. Refer to Attachment 7 to complete the California 5020 Form NOTE: The California 5020 and the Supervisor’s Report of Illness and Injury are to be completed and mail within 24 hours of the knowledge of the injury. The work site supervisor should not wait for the DWC-1 to be return by the participant or for any medical reports. Completion of the California 5020 is not an admission of liability on the part of the CWEX site provider.
b. Scan and E-mail or fax the original to:
[email protected]
Or
CWEX FAX #: (916) 875-3302
Sacramento County Department of Human Assistance
ATTN: CWEX Supervisor
1725 28th Street
Sacramento, CA 95816
c. Keep copies for own records
Questions related to the completion of claims, reporting forms, or the administration of benefits by Intercare is to be directed to the CWEX Supervisor, listed above.
A fillable electronic DWC-1, revised 1/1/2016, can be found at:
https://www.dir.ca.gov/dwc/dwcform1.pdf
A fillable electronic CA 5020 can be found at:
https://www.dir.ca.gov/dosh/DoshReg/Form5020.pdf
If a CWEX participant is kill or sustains a serious injury, the work site supervisor should immediately report the incident by telephone to the nearest office of the California Department of Occupational Safety and Health (DOSH).
Sacramento District Office
1750 How Ave, Ste. 430
Sacramento, CA 95825
(916) 263-2800 [email protected]
The work site supervisor must also immediately contact the CWEX Supervisor at (916) 874-0945 and email [email protected]
“Immediately” means as soon as practically possible but no later than eight (8) hours after the employer knows or with diligent inquiry would have known of the death or a serious injury or illness. Immediate reporting also applies to injuries or illnesses initially determined to be non- serious, but later fall within the definition of a serious injury or illness. 13 Reportable Incidents
The Sacramento County Community Work Experience (CWEX) Program has established the "Incident Report Policy and Procedures” for use by agencies to provide the CWEX Program with basic information regarding incidents which occur at your worksite.
This can include, but is not limited to:
• Death of any client from any cause
• Any facility-related injury of any client
• Any event interpretable as Workplace Harassment
• Any event interpretable as Workplace Violence
• All cases of reportable communicable disease
• Any event interpretable as Sexual Harassment
• Fires or explosions that occur in or on the premises
• Poisonings
• Incidents involving emergency services at treatment facility
• Catastrophe or other natural disaster
Steps to follow when there is an incident
1. Complete the Provider Incident Report, included. (Attachment 9)
2. Complete any necessary supporting documents
3. Email completed forms to [email protected] 14 APPENDIX
This appendix contains the documents referenced throughout this handbook.
1. Notice to Employees (SC 246.211)
2. Referral to Community Work Experience (CWEX) Program Worksite (WTW 1021_34F)
3. CWEX Time and Attendance Record (WTW 1048_34F)
4. Participant Progress Review Form (SC 246.86)
5. Request for Live Scan Service (BCII 8016)
6. Employee Claim Form (DWC-1)
7. Employer’s Report of Occupational Injury or Illness (CA 5020)
8. Supervisor’s Report of Illness/Injury – County Of Sacramento DHA-CWEX
9. Provider Incident Report
15 DHA Director
Ethan Dye
Sacramento County Board of
Supervisors:
District 1 – Phil Serna
District 2 – Patrick Kennedy
District 3 – Rich Desmond
District 4 – Sue Frost
District 5 – Don Nottoli
County Executive Officer
Ann Edwards
www.saccounty.net/dha