Untitled SIS. SARAH CHURCH OFFICE FAX 801-393-4153 801-392-2911 801-392-3433 EMAIL newzionut.com EASTER SEALS: FLLENDOLOCK SHARON (SLC) FAX 801-626-0351 801-556-7115 801-556-7065 Page | Host Agency Participant Injury Packet When a SCSEP participant is injured badly enough to require medical attention, stress levels rise and things happen quickly. As a result, often times the required forms that need to be filled out and given to the participant sometimes get missed. To make sure that accident procedures for SCSEP participants are followed we have devised this participant injury packet for your use. Please keep copies of this packet in a convenient place so that if an accident happens the required forms are readily available. | The Injury Packet contains: | 1. Easter Seal Goodwill Injury/Near Miss Reporting Form 2. ERTW policy statement to physician Return-to-work recommendations form AIGCS RX firstfill form Tymesis Pharmacy 5-06 The second grouping of forms is what is needed to give to the participant to take with them to their medical appointment. The pharmacy forms assist injured workers get prescribed medication quickly without an initial out of pocket expense to them. The injured participant should take this form with them and give it to their pharmacist at the time of placing a prescription. Participating pharmacies are located on one of the sheets. Please. contact (add your name) at (put in your phone #) as soon as possible to alert them that a participant has suffered an injury. If the SCSEP staff person is not able to come out to the site of the accident, please fax the Injury/Near Miss Reporting Form to (add your name) at (add your fax) The Return to Work Recommendation Form should be filled in by the physician and faxed or given to (add your name) once the doctor is sure the participant can return to work. (Add your name) will discuss with you if a change of duties or placement is needed for the participant to return to work. We thank you for your coopepption. Sincerely. Ellen Dolock Easter Seals SCSEP (810) 626-0351 -‘Update Injury Management & Claims Reporting Procedures Step One: 4 The Injured worker notifies his/her Supervisor in the Host Agency regarding the injury. In the case of a life threatening injury, CALL 911! Step Two: The Supervisor, with the participant, immediately calls Medcor at 1-800-77 35-5866 to speak with a medical professional. _If possible the supervisor should also contact the SCSEP case manager at this time. Step Three: A medical professional gathers relevant information from the Supervisor and speaks to the injured employee. The medical professional recommends a course of action that includes: = On-site first aid treatment procedures = Home-care treatment procedures " Or, if needed, referral to the designated medical facility (IHC) for treatment. = Shares course of action with supervisor. Step Four: Medcor immediately begins the claim management process. In the case of an injury that is NOT referred to an IHC facility. = The Supervisor fills out the INJURY/NEAR MISS REPORTING FORM and faxes it to Easter Seals Northern Rocky Mountain Safety Officer at (208) 378-9965 within 24 hours. In the caseof an injury that is directed to the designated medical facility (IHC): = « = The Supervisor fills out the INJURY/NEAR MISS REPORTING FORM and faxes it to Easter Seals Northern Rocky Mountain Safety Officer at (208) 378-9965 within 24 hours. The participant takes the ERTW policy statement and the Return-to-work recommendations form to IHC. Medcor will also send information to IHC. All injuries should be called in to Medcor On-Line 1-800-775-5866. Injuries must be reported toEllen Dolock 801-626-0351, Steve Miller 801-626-0351 Jean Richter 801-536-7009, Larry Witherow, 801-554-2051, or Janet Wade 801633-2091 as soon as possible. Creating solutions, changing lives +r. a Ww eee ee eT Ree e eer 7 3 . a ee ee a Easter Seals a wos ow DiS ~ re | a oo f 3 a] . ¢ as S i 5 HLS j x “ r e cy % aA e eee a ow Be goodiuill * * :Me ‘ 3 5 : % ‘January/19/2009 Accident Procedures Once you have been informed that an accident has happened contact Jean Richter. If the accident occurs on the weekend/holiday contact Janet Wade. Please print out copies of this packet. Provide each host agency with several packets. Include in the host agency packet the host agency cover sheet. The safety forms should be reviewed during host agency orientation and during yearly participant reviews. Make sure the host agency has your contact information. The host agency must contact you as soon as possible after the accident. If the host agency is located a distance from the office and you are not able to pick up the paperwork make sure the host agency knows that the Injury/Near Miss Reporting Form has to be faxed to Drew Wattles within 24 hours. If possible go out to the accident site to check on the participant. Make sure that the participant has access to appropriate medical care if needed. If the host agency is located at a rural site make sure the host agency has filled in all the paperwork and faxed you a copy. The following forms should be filled out at the time of the accident. Easter Seal Goodwill Injury/Near Miss Reporting Form If the participant did not seek medical attention fax section 1, 4 and 5 within 24 hours, to the Safety Officer Drew Wattle. : If the participant did seek medical attention fax all the sections filled in within 24 hours to the Safety Officer Drew Wattle. If the participant seeks medical attention you need the following forms for the participant to take with them to take to the doctor: ERTW Policy Statement to Physician Return to Work Recommendation The participant must have a copy of the Return to Work Recommendation Form to give to the doctor. Once the doctor recommends that the participant can return to work The Return to Work form should be faxed to the Safety Officer. Make sure you have a copy as the information on this form will also help on reassigning the participant to a new host agency if the injury prevents the participant from performing tasks required by his/her present placement. If the participant needs medication the participant will need the following forms: AIG claim Services Injured Worker's Prescription Information Sheet and the list of pharmacies: AIG Claim Services and Timesys Pharmacy Benefits Management Program The form below is a good form to help you decide whether an accident victim needs medical attention: Cheat Sheet for Injuries Requiring Medical Attention In Easter Seals we are hoping to build a safe environment. The Employee Counseling Report for Safety Violations and/or Causing Preventable Vehicle Accidents and Injuries form is only used when a participant has been continuously warned of dangerous behavior. “ 06/15/2009 —~de 09:06 FAX 801 536 7011 DWS METRO ’ Accident Procedures In the event of an accident use the following form: Easter Seal Goodwill Injury/Near Miss Reporting Form If the participant did not seek medical attention fax sectio n 1, 4 and 5 within 24 hours, to the Safety Officer Drew Wattle. If the participant did seek medical attention fax all the sections filled in within 24 hours to the Safety Officer Drew Wattle. If the participant seeks medical attention you need the following forms for the participant to take with them to take to the doctor: ERTW Policy Statement to Physician Return to Work Recommendation The participant gives these forms to the doctor who fills in the Return to Work form. The Return to Work form should be faxed to the Safety Officer. If the participant needs medication the participant will need the following forms: AIG claim Services Injured Worker's Prescripti on Information Sheet and the list of pharmacies: The Safety Officer is going to check whether we need the post-accident drug screen. We are thinking that we will not need this for participan ts. There is a good form to help you decide whether an accident victim needs medical attention: Cheat Sheet for Injuries Requiring Medical Atten tion In Easter Seals we are hoping to build a safe envi ronment. The Employee Counseling Report for Safety Violations and/or Causing Preventable Vehicle Accidents and Injuries form is only used when a participant has been continuously warned of dangerous behavior. [24}004/013 . 06/15/2009 09:06 FAX 801 536 7011 DWS [27}004/013 METRO Accident Procedures In the event of an accident use the following form: Easter Seal Goodwill Injury/Near Miss Reporting Form If the participant did not seek medical attention fax sectio n 1, 4 and 5 within 24 hours, to the Safety Officer Drew Wattle. If the participant did seek medical attention fax all the sections filled in within 24 hours to the Safety Officer Drew Wattle. If the participant seeks medical attention you need the follo wing forms for the participant to take with them to take to the doctor: ERTW Policy Statement to Physician Return to Work Recommendation The participant gives these forms to the doctor who fills in the Retur Return to Work form should be faxed to the Safety Office r. n to Work form. The If the participant needs medication the participant will need the following forms: AIG claim Services Injured Worker's Prescription Information Sheet and the list of pharmacies: The Safety Officer is going to check whether we need the post-accident drug screen. We are thinking that we will not need this for participants . There is a good form to help you decide whether an accid ent victim needs medical attention: Cheat Sheet for Injuries Requiring Medical Atten tion In Easter Seals we are hoping to build a safe environmen t. The Employee Counseling Report for Safety Violations and/or Causing Preventabl e Vehicle Accidents and Injuries form is only used when a participant has been continuously warned of dangerous behavior. - 06/15/2009 09:06 FAX 801 536 7011 DWS METRO 005/013 EASTER SEAL GOODWILL INJURY/NEAR MISS REPORTING FORM This report is to be completed by a supervisor in ink as soon as possible after the occurrence of any on-the-job accident, injury or near miss. The report and any witness statements are to be faxed to the Safety Officer at (208) 378-9965 within 24 hours. Feel free to cal] the Safety Officer at (208) 378-9924. If after submission of this report, outside medical treatment is obtained and/or the employee loses. time due to the work-related injury, the supervisor should call the Safety Officer. Check one: |_| A work related injury or near miss that did not require outside medical attention L_] A work related injury requiring outside medical attention Fill out Parts 1,4 & 5 PART 1 Fill out Parts 1 - 5 Employee Information Name of Employee: Phone Number: Job Title: ( Program: ) City: urate Time: PM AM What specific object or substance caused the incident? Mark on Picture Location & Type of Injury. Scratch Laceration Bruise Bite Swelling Other — Describe what happened and how it happened. Explai n what you were doing when incident or accident occurred. Give full details on all factors which led or contributed to the incident. Use a Separate sheet of paper if necessa ry. Was the employee exposed to another person’s blood or other body fluids? Whose? (_} Yes L] No Be specific. - 06/15/2009 09:06 FAX 801 536 7011 PART 2 ae DWS [006/013 METRO Medical Treatment Medical Treatment: [-] None [_] On-site by staff (minor first aid only) Attending Physician’s Name: L] Clinic / Dr. Office Address: [7] Emergency Room/ City: State: Hospital Zip: Phone # ( If Hospitalized, hospital name: | Address: City: State: Zip: Phone # ( PART 3 Soc. Sec. # Home Address: City: Phone # : ) State: Education: [_] - Less than High School (_] Single Employment Status: [_] Full-Time Hourly Wage: é [_] Part-Time Did worker return to work during next scheduled shift: ([JNo If no, will wage loss exceed 4 | work days: | LJyYes Marital Status: (_] Married [_] GED or High School [_] Beyond High School Date Hired: L}Yes y Employee Details for Worker’s Com pensation Date of Birth: ~|( ) [JNo [_] Not Sure Zip: # of Dependents: # of days worked per week: $ Regular days off: Date Last worked: Date Returned to work: 06/15/2009 PART | 09:06 FAX 801 536 4 7011 DWS [4}007/013 METRO Witness Information Please list anyone who witnessed the in jury or near miss and have them com plete a Witness Statement 1. 3. Z. 4. Witness Statements (Each witness should submit a separate statement) Witnesses Name: Number where you can be reached: ( ) Describe how the accident ha ppened. Explain what the worker was doing when injured. Give full details on all factor s which led or contr ibuted to the you need additional space. Signature of Witness: accident. Be specific. Use a separate sheet of paper if Date: .96/15/2009 09:06 FAX 801 536 DWS 7011 METRO [71008/013 * PART 5 Investigation Report To be completed by: - Supervisor for injuries and near misses not requiring outside medical treatment - Accident Review Committee for Injuries requiring outside medical treatment Employee’s Name: Accident Date: Program Name/Location: Date Investigated: Brief description of incident / accident: Direct Causes: Indirect Causes: Prevention Recommendations: (additional safety traini ng, video, protective equipment, etc.) Review Committee Members: Name Signature Job Title Date Employee Comments: pe see ee eee me Employee Signature SE / Date orms/Injury — Near Miss Reporting Form 3-08 | _ — Supervisor Signature / Date _ °06715726009 09:06 801 FAX 536 DWS 7011 4009/0138 [f) METRO ERTW Policy Statement to Physician Dear Dr. Easter Seals—Goodwill believes our employees are the most important assets of our company and we are interested in safeguarding their jobs. If they are unable to return to their full duties immediately, we will do everything possib le to modify those duties. We are committed to assisting our injured employees return to work as soon as medically appropriate and to work with the medica! community to help the injured employees regain their livelihood. We are willing to work their schedules appointments, if necessary. Please assist us by providing capacities following every appointment. around medical restrictions or functional Our Early Return To Work program focuses on modify the employee’s existing position and/or work schedule temporarily, or to create a positi on to accommodate the temporary physical restrictions identified by the treating medical provider. If the injury results in permanent restrictions we will strive to accommodate in compliance with the Americans with Disabilities Act (ADA). Drew Wattles is our Safety Officer and our Early Return To Work liaison. If you have any questions about our Early Retum to Work Program or you would like to learn more about our safety programs, please contact Drew at the numbe r or email listed below. = : We are including a Return to Work Recommendation form. Please complete one for each appointment. We are looking forward to working with you to ensure a safe and permanent return to work for our employee. If any proble ms are encountered when our employee returns to work, please call Drew so we can modify rather than eliminate the transitional job. Thank you for your assistance with this matter. Sincerely, Drew Wattles Safety Officer Easter Seals-Goodwill 1465 S. Vinnell Way Boise, ID 83709-1659 _, Phone: 208-378-9924 Fax 208-378-9965 dreww@esgw.org , 06/15/2009 FAX 09:07 801 536 | 7011 DWS METRO id 010/013 NORTHERN ROCKY MOUNTAIN EASTER SEAL SOCIETY/GO ODWILL INDUSTRIES RETURN-TO-WORK RECOMMENDATIONS To be completed by physician or other medical provider: Patient: Patient may resume duties with no restrictions on (2) Patient may resume modified duties on In an 8-hour workday, patient can stand/walk: {} 0-2 (Hours at one time) {] 2-4 (] 4-6 {} 6-8 In an 8-hour workday, patient can sit: (Hours at one time) {} 0-2 [] 2-4 [] 4-6 {] 6-8 [] No restrictions (Total hours during day) [] 0-2 [] 2-4 {] 4-5 {} 6-8 [} No restrictions {] 0-2 In an 8-hour workday, patient can drive car/truck: (Minutes at one time) (Hours at one time) 1110-30 = {] 30-60 {] 1-3 | Pe within the following limits: (Total hours during day) {] 2-4 {} 4-5 {] 6-8 0 No restrictions Patient can lift/carry: ) No restrictions "Heavy labor activity” means the ability to lift over 50#'s occasi onally or up to 50#'s frequently: “Medium labor activity” means the ability to lift up to S5O#' S occasionally or up to 25#'s frequently: "Light labor activity" means the ability to lift up to 25#'s occasionally or up to 10#'s frequently: “Sedentary labor activity” means the ability to lift up to 10#'s occasionally or up to 5#'s frequently: Patient can use hands for repetitive: {] No restrictions Simple Grasping Pushing & Pulling Fine Manipulation yes [Jno yes [Jno yes [Jno Patient can use feet for repetitive movement as in operat ing foot controls: [Jno flyes Patient is able to: Bend Squat Kneel Climb Reach Frequently 0) 0 8 0 Q Occasionally 0 (] f] tt 0 {] No restrictions Not at all (] Q 0 U ls patient restricted by environmental factors, such as heat/cold, dust, dampness, height, etc? ) No restrictions } Yes - Please explain: Will patient be required to use any assistive device s or braces? {] No restrictions {} Yes - Please explain: | ls patient involved with treatment and/or medication that might affect his/her ability to work? [] No restrictions _. ..{] Yes - Please explain: (4) Duration of limitations indicated above: (5) Next appointment: (6) Physician’s signature: Date: oonmacwa (1) Claim# 06/15/2009 09;07 FAX 801 536 7011 DWS [4011/013 METRO AIG Claim Services Injured Worker’s Prescription Informatio n Sheet TAKE TO PHARMACY Injured Worker Name: #: Social Security Date Of Injury: Dear Injured Worker, On your first visit, please give this notice to an y pharmacy listed on this insert to expedite the processing of your approved Worker's Compensation prescriptions, based on the established parameters by AIG Claim Services. Dear Pharmacist, Please call the Tmesys™ Pharmacy Help Desk, 1 -800-964-2531, to-establish First Fill eligibility and obtain the ID# necessary for the online processing of Worker’s Compensation medication for this newly injured ( “mesys'” _ worker. Your company has signed an agreement to participate in the Workers’ Compensation PPO. Please contact the Tmesys™ Pharmacy Help tmesys .vesk and inform the Tmesys™ Help Desk Representative that there is a newly injured worker at your pharmacy filling an AIG Claim Services First Fill prescription. Sincerely, Tmesys™ CHAIN NAME _ A&P Arbor Drug Bartel] 8B CVS Drugs_ Fair ard ALL PARTICIPATING PHARMACIES HAVE INDEX NAME CHAIN NAME Index: TYS Casrier code: TI Index: TMS all others Franck's Pharm Fred Fred's Ph Genovese Glam E. Giant Ph Goodin Hannaford Food A Orug Brooks& Horizon Hy Veo JaJ Joal & s K 4&8 Kash N Kary Condar Coda: 8822 Kerr TYs index: TMESYS K-mart ermim ad ermimnal plan:2801 Drugs Lifecheck 's code: TM X{HIS) CHAIN NAME index: TME index: TYS TMESYS Central Pic & Save Prevo code: TM0 1} Publix jindex: TME TYS index-bin # in 3rd Tcs [wos Me Plan code: TMESYS ee TYs Randaits Reveo Rike-Aid RX Discount Sack-n-Save S Sav-A-Lot ics code:TY '/Bel Air set TMESYS Carrier code: TYS index: TS. TM YS TMESYS lan: #1, TMES Medicine TMESYS Now Eckerd Index: TME (Do not usa WC TMESYS TME index D, bill code TME index TYS [INDEX NAME HEB Carrier code: TYS kypul code: TMS index: TMESYS Code: TME Condor Codec 2050 index: Cal Camer Code: TYS TY3 NOT BEEN INCL UDED ON THIS LIST. PLEASE CALL TMESYS REGARDING ANY QUESTIONS H Harry's Harco Hi-S.chool Pharm index: TYS Bi-Lo Pharm Bit Mart Brooks s Brook shire Brothers Cardinal Heaith Cub Pharm Eck Inc. Phar-Mor Se Save Mart N varies by each siore [Super compensation as Tom Ashley Super X (HSI) use “Separate Pian Number” code Sams Club Ph eel Tys Super Vali Theift The P Tom Thumb Tops Pharm Tri Daly Orugs jplan INDEX NAME CHAIN NAME name: T or YMESYS , code: TS carrier. TME plan: SYS or TYS Tumer Twain Value |U-Save TMSRX TMAWC TMESYS code: TME t 6012 or 5097 code: TME or TYS Vona Vix Ww Waltart lan: Ti Cartier code: TME (800) 964-2531 United INDEX NAME Index: T: carrier code: TYS index. TME TYs | Wais Markets Winn-Dide carier: TME Caier code: TME Carrier code: TMEWC carrier. TME Cesrier code: TME carrier code: TYS index: TME (plan 20608 Carrier code: TYS Tys TYS 146 NOT BEEN INCLUDED ON THIS LIST. Plan name:si2 PLEASE HAVE YOUR PHARMACY CALL indax. TME QUESTIONS/AUTHORIZATIONS carrier code: TYS carrier code: 4139 2066 code: TMS access code: T] Carrier code: TMS —~ TMESYS REGARDING ANY (800) 964-2531 . | o 20°60 60027S1790> Pharmacy PPO a Network A&P Abco ACME AIG] Costco Pharmacies CRX CVS D&W Food Centers Dahl's Davidson Drugs Delchamps Dierberg's Dillion Discount Drug Mant Dominick's Drug Emporium Drug Fair Eagle Eckerd Drugs Emm-Dee Drug Inc. Encara Performance Net Erickson's Diversified Fagen Fred’s Pharmacy Fruth Fry’s Food Store Furr’s Genovese Drug Stores Gerland’s Family Giant Eagle Giant of Maryland Gooding Grand Union Greens Drug Store Gresham Drug HEB Haggen Foods Hannaford Brothers Happy Harry's Drugs Harmons Pharmacy Harps Food Stores Hawkings Apothecaries H-School Homeland King Kullen King Soopers Kinney Drugs Kiowa Pharmacy Klinck Drug Stores K-Man Kohils Pharmacy Kroger Food & Drug LML Enterprises Longs Drug Louis & Clark Louis Morgan Drugs Lovel]'s Discount Drugs M&H Drugs Inc. Marsh Drug Store Mays Drug Stores Medco Drugs Medicap Medicine Shoppe Medisave Med-Rx Drug Med X Drug Meijer Minyard Food & Drug 9€S Horizon Pharmacy Hospital Drugs Hy-Vee Inserra Supermarket Kash n° K Keltsch Kerr Drugs Kessel Keystone “Te FT TTOZ College Concord Drugs Consumer's Copps Family Drug Farmco-Drug Center Farmer Jack Fedco Professional Felpcusch Pharmacy Foodarama Four-B Corp. Fred Meyer Nash Finch Company Neighborcare Owl Drug Stores P&C Food Market Pathmark Perlmart Pharmacy Plus Pharmhouse Phar-Mor PHP Healthcare Corp Poik's Discount Drugs Price Choppers Price Less Drugs Price Wise Pharmacy Professional Village Publix Quality Food Centers Quality Markets Raley’s Drug Center Ralph’s Pharmacy Randall's Revco Discount Drug Rite Aid RxD Pharmacy Ronetco Rosauer’s Safeway Save Mart Sav-mor Drug Stores Schnucks Sedano’s Discount Sedell's Sentry Drugs Shaw’s Supermarket Shelley's Shopko Shoprite Smith Food & Drug Snyders Drug Store Stadianders Pharmacy Star Market Stop & Shop Super D Drugs Super Fresh Pharmacy Super Sav-On Drugs Super Value Thrift Drug Store Thrifty Payless Inc. Thrifty-White Drug Tidyman’s Tom Thumb Pharmacy SMC C Pharmacy Center Circle Drug City Market Coleman Pharmacy Tops True Quality Ukrops Supermarkets USA Dmg & Beauty Value Health Center Vencare Pharmacy Village Supermarket Von’s Pharm Waldbaums Walgreens Wal-Mart Wegman “ Ht *,' . 5 Weis Winn Dixie AIG Claim Services Services Provided by Members of American international Group, inc. 78307 CS/1SM 1/05 €T0/cloy J } Carr Quality Center OULYN Arrow Prescription Centers Balls Four B Corp. Bartell Drug Big Bear Big V Bi-Lo Bi-Mart Drugs Brooks Maxi Drug Brookshire Bros. Brookshire Brown & Cole Inc. Bruno's Food Buchler Buy-Wise Discount Caldor TO8 ae (OH) Alaco Discount Pharmacy Anchor Pharmacy Appalachian Reg. Healthcare Arbor Drugs XV Plus...Many Neighborhood Ind ependent Pharmacies 66/15/2009 | | r 09:07 FAX 801 536 7011 DWS [4013/013 METRO » EMPLOYEE COUNSELING REPORT FOR SAFETY VIOLATIONS AND/OR CAUSIN G PREVENTABLE VEHICLE ACCIDENTS & INJURIES 7 Name: Position: Department: Supervisor completing report: | Date: 1. Type of Action (i.e. warning, suspension etc.) 2. Describe the incident and tmpact on job or company: 3. Expected performance standards in the future: Compliance with safety rules and performing job duties in a safe manner. 4. Next action if employee does not meet the expec ted standards: and including termination of employment. Further disciplinary action up to 5. Employee comments: Safety Violations Number of occurrences in a 2-year period: Preventable Vehicle Accidents and Injuries Number of occurrences in a 3-year period: 1. Verbal warning /retraining 2. Written warning/retraining 3. Suspension/Safety or driver retraining 4. Termination Dates of Safety Violations 1. Written warning/Safety or driver retraining 2. Suspension/Safety or driver retraining 3. Termination Dates of Preventable Vehicle Accidents & Injuri es I have received a copy of this Employee Counseling Report and understand it will be entered into my personnel records. ‘on « Employee Signature H:\Forms\empicounselingaccidents | Date = Supervisor/Manager Signature / _T Date Easter Seals Northern Rocky Mountain Region Senior Community Service Employment Program Vacation Schedule The transition from Easter Seals Inc to Easter Seals-Goodwill Northern Rocky Mountain Inc has brought about a change in the holidays observed for all SCSEP participants. The following holidays will be observed: New Year’s Day Memorial Day Independence Day Labor Day Thanksgiving Day Christmas Day KJUUSSUUS 63/17/2089 12:15 . EASTER SEALS SCSEP PAGE Easter Seals Utah Senior Community Service Employment Program Pay Cycle Period Begins . 8815249216 Saturday Time Sheets Received By Checks Monday Thursday Period Ends | Easter Seals Friday _NOON Mailed Checks Received = Friday Mar-21-09 | Apr-03-09 Apr-06-09 Apr-09-09 | Apr-10-09 Apr-04-09 | Apr-17-09 Apr-20-09 Apr-23-09 | Apr-24-09 Apr-18-09 | May-01-09 May-04-09 May-07-09 | May-08-09 May-02-09 | May-15-09 May-138-09 May-21-09 | May-22-09 May-16-09 | May~29-09 June-01-09 | June-04-09 | June-05-09 May-30-09 | June-12-09 June-15-09 June-18-09 | June-19-99 June-13-09 | June-26-09 June-29-09 July-02-09 | July-03-09 June-27-09 | July-10-09 July-13-09 July-16-09 | July-17-09 July-24-09 July-27-09 July-30-09 | July-31-09 July-11-09 | 61/61 New Zion Community Advocates, Inc. 2929 Lincoln Ave., Suite B Ogden, UT 84401 Job Description for Easter Seal Volunteer(s): Office Assistant — Job Title Part Time - 20 Hours per Week Time: 11:00 a.m. — 3:00 p.m., Monday - Friday (Negotiable) Wage — N/A Duties: e Answer telephone and direct calls. e Maintain materials and boxes for educational presentations. e Assist in assembling and setting up information booths at community awareness functions. Maintain and set-up all office files. Type reports and other information as required. Photocopy and assemble materials. Call board members monthly to remind them of meetings. Assembly packets for monthly board meetings. Spend two hours a week learning computer skills, accounting software and other software applications used by the project. e Other duties as needed to support the Project. Note: Days and hours will be negotiated with the Senior Pastor. Name: Kathleen Jordan — 231-286-9407 Btant late 5/20) O7 Revised 04/15/09 Easter Seal Volunteer eee ee he Some Duties for Discussion: Set-up files for the Trustee Board Type Christian Leadership Booklets Shear Documents Print, Type, and Cut Weekly Bulletins Answer Phone and Take Messages Call Members About Board Meetings Type Thank You Letters Using a Template Maintain the Easter Seal Book Spend two hours a week learning software application Office Space Suggestion: 1. Move the copier out of the front office to the porch office and move the spare desk in Sister Davis office to the front office. Supervision: 1. 2. 3. 4. Evaluation Annually Sign Payroll in your Absence Complete Forms as Needed Approval of Sick Leave in your Absence (Who to Call?) Revised 04/15/09 E-mail Groups Youth Group "Gray, Pat" <patoutshopping7@yahoo.com>; AricaNia3@comcast.net; afsattie@kcc.com; loveyh@q.com; chouse@OWCAP.ORG; Burks. Brenda@jobcorps.org; brucedavisministries@comcast.net; Executive Officers chouse@OWCAP.org; twhite12@msn.com; wilson.english@hill.af.mil; tlarry@utah.gov; drceac@msn.com; rolandrbrown@gmail.com; swainbrown@hotmail.com; mrsjonesS6@comcast.net; ogdn.harry@msn.com; newzionpastor@aol.com; dcarpenter@OWCAP.ORG; newzionut@aol.com; sediamon@msn.com; wbrock@peoplepc.com; dovedeelong@yahoo.com; ogdn.harry@msn.com; dixpatches@aol.com; white. Thomas@jobcorps.org; Trustee Board "Dixon, James" <dixpatches@aol.com>; "Fullwiley, Terry" <fullwileyt@msn.com>; "White, Thomas" <twhitel12@msn.com>; "Hairston, Lovey" <loveyh@q.com>; "Brown, Roland" <rolandrbrown@gmail.com>; "Carpenter, Donald R." <dcarpenter@OWCAP.ORG>; New Zion Community Advocates "Davis, Sabrina" <brucedavisministries@comcast.net>; rolandrbrown@gmail.com; newzionpastor@aol.com; dcarpenter@OWCAP.ORG; kittys@usdb.org; ltraum@OWCAP.org; kenneth.D.wilder@irs.gov; nuc536@comcast.net; ai a ~— fe ~ “wv wv wae ~—2s 63/17/2889 w= 12:15 | ~~ 2462 ww. ~~ /s : (wiwy 8815249216 wyscti DY & gjo03/003 WODSL EASTER SEALS SCSEP PAGE Easter Seals Utah Senior Community Service Employment Program Pay Cycle Period Begins Saturday a Time Sheets Received By Period Ends | Easter Seals Friday Monday NOON Checks Checks Mailed Thursday Received Friday Mar-21-09 | Apr-03-09 Apr-06-09 Apr-09-09 | Apr-10-09 Apr-04-09 | Apr-17-09 Apr-20-09 Apr-23-09 | Apr-24-09 Apr-18-09 | May-01-09 May-04-09 May-07-09 | May-08-09 May-02-09 | May-15-09 May-18-09 May-21-09 | May-22-09 May-16-09 | May-29-09 June-01-09 | June-04-09 | June-05-09 May-30-09 | June-12-09 June-15-09 June-18-09 | June-19-09 June-13-09 | June-26-09 June-29-09 July-02-09 | July-03-09 June-27-09 | July-10-09 July-13-09 July-16-09 | July-17-09 July-11-09 July-27-09 July-30-09 | July-31-09 | July-24-09 61/81 se SSO coy . + 7 — _— apr : une sw wr ww Ow Ye be ee Wj002/003 OND LL Senior Community Service Employment Program Participant Time Sheet FAX NUMBER 801.524.9216 Time Sheet for Period: / to. f/f Name of Participant:| Training Assignment Title:[_ Host Agency:[ Commanity Service Day/Date | {T#ining Hours, Job} ay Club, Participant 5, Meetings, ete Approved | Training Training Received: Ady.{ | Holiday | Specialized | Describthe e Typeof Hours ee 1 tal Hours de not incinde general oversight in hours | —Hours__|__ Comp. CDL, ete. TOTALS | as a The undersigned hereby certify that the reported inform ation is correct for the re porting period. Print: Total Hours of Supervision: Name of Participant Supervisor's Time Spent Training Participant Signature of Participant Date Host Agency Supervisor Signature/Date l certify that this time is correct. Por Project tse Outs Total Training Hours: | | Total other training | ea ea ol hours*: Total hours in Specialized T, raining Approved By: SCSEP Program Manager or authorized representative Participant Timesheet __. l of | 7/10/06 04/21/2009 TUE 63/17/2889 12:02 FAX 801 394 12:15 8815249216 7375 Ogden EC 2 [Z}003/003 West EASTER SEALS SCSEP PAGE Easter Seals Utah Senior Community Service Employment Program Pay Cycle Period Begins Saturday Time Sheets Checks Monday Thursday Period Ends | Easter Seals Friday Mar-21-09 | Apr-03-09 Apr-04-09 Received By | Apr-17-09 | Apr-06-09 Apr-20-09 Mailed Checks Received Friday | Apr-09-09 | Apr-10-09 Apr-23-09 | Apr-24-09 Apr-18-09 | May-01-09 | May-04-09 | May-07-09 | May-08-09 May-02-09 | May-15-09 | May-18-09 | May-21-09 | May-22-09 May-16-09 | May-29-09 June-01-09 June-04-09 | June-05-09 May-30-09 | June-12-09 June-15-09 June-18-09 | June-19-09 June-13-09 | June-26-09 June-29-09 July-02-09 | July-03-09 June-27-09 | July-10-09 July-13-09 July-16-09 | July-17-09 July-11-09 | July-24-09 July-27-09 July-30-09 | July-31-09 61/81 04/21/2009 we ¢ SO . an TUE 12:01 aamera FAX 801 394 7375 Ogden EC 2 West Easter Seals FT sors: _: scswgesw et [Zj00 2/003 ~ Senior Community Service Employment Program Participant Time Sheet FAX NUMBER 801.524.9216 ‘Time Sheet for Period: Lt Name of Participant:| to / I | | Recap Training Assignment Title:| Community Service Day/Date Approved Training Hours, Job Club, Participant Meetings, Brain Host Agency:| Holiday | Specialized OJE Hours. | ‘Tratuing ete_ |. Hours Describe si Type of Training Received: Ady.j Comp., CDL, etc. ! otal Hours , TOTALS Pe — RR The undersigned hereby certify that the reported information is correct for the reporting period. Print: Name of Participant Signature of Participant Date Total Hours of Supervision: | Supervisor's Time Spent Training Participant _ Host Agency Supervisor Signature/Date 1 certify that this time is correct. For. Project Use One Total Training Hours: | | | Total other training | -hours*: Total hours in Specialized Training Approved By: SCSEP Program Manager or authorized representative Participant Timesheet : l of | 7/10/06 New Zion Community Advocates, Inc. 2929 Lincoln Ave., Suite B Ogden, UT 84401 Job Description for Easter Seal Volunteer(s): Office Assistant — Job Title Part Time - 20 Hours per Week Time: 11:00 a.m. — 3:00 p.m., Monday - Friday (Negotiable) Wage — N/A Duties: Answer telephone and direct calls. Maintain materials and boxes for educational presentations. Assist in assembling and setting up information booths at community awareness functions. Maintain and set-up all office files. Type reports and other information as required. Photocopy and assemble materials. Call board members monthly to remind them of meetings. Assembly packets for monthly board meetings. Spend two hours a week learning computer skills, accounting software and other software applications used by the project. Other duties as needed to support the Project. Note: Days and hours will be negotiated with the Senior Pastor. Debbie Rodenbough — 801-782-4581 Revised 04/15/09 Easter Seal Volunteer Debbie Rodenbough 801-782-4581 ie oll aE el el sale ill Some Duties for Discussion: Set-up files for the Trustee Board Type Christian Leadership Booklets Shear Documents Print, Type, and Cut Weekly Bulletins Answer Phone and Take Messages Call Members About Board Meetings Type Thank You Letters Using a Template Maintain the Easter Seal Book Spend two hours a week learning software application Office Space Suggestion: 1. Move the copier out of the front office to the porch office and move the spare desk in Sister Davis office to the front office. Supervision: 1. 2. 3. 4. Evaluation Annually Sign Payroll in your Absence Complete Forms as Needed Approval of Sick Leave in your Absence (Who to Call?) Revised 04/15/09 DISABILITY SERVICES an Prise Bre Bera Rar Bare Pre SR ne Penn M® 2 : Easter Seals Ellen Dolock Utah Job Developer/Employment Specialist SCSEF Easter Seals d/o Utah Department of Workforce Services 480 27th Street Ogden, Utah 84401 801.626.0351 phone 801.394.7375 fax edolock@easterseals.com www.easterseals.com