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On the Job Training Agreement Checklist <br />BUSINESS NAME: Americare Respiratory Services, Inc. <br />1. Pre Award Survey <br />2. OJT Agreement Template: Training dates (pg 1'?', reimbursement rate (pg 1 and 5j/ ? <br /> maximum reimbursement amount (pg 4?and Employer Info (pg S?match Exhibit A- <br /> Training Plan. <br />3. Exhibit A: Training Plan <br /> V OJT's to employees do not exceed 1-5 ratio ? <br /> EA SVP Level is => 34- <br /> [P of Training are reasonable <br /> J?l Cost Computation is in accordance hourly wage 50% of wages or sliding scale based <br /> on number of employees per DOL waiver. <br /> lSigned by Employer <br />4. Exhibit B: Assurances L/ <br /> In <br />? <br />5. Exhibit C: Insurance commercial/workers comp for 1,000,000 with Additional Insured ? <br /> Endorsement naming City of Santa Ana as Additional Insured. <br />6. Exhibit D: Drug Free Workplace Form completed and signed. ? <br />7. Exhibit E: Debarment Certification signed. ? <br />8. Exhibit F: For ARRA Agreements contains ARRA Requirements. N/A ? <br />9. File: <br />ADA Survey ? ? <br /> EEO & Grievance Procedures <br /> W9 and W9 Request Forms,/ <br />10. Three copies of agreement and canary routing slip attached ? <br />Comments <br /> <br /> <br />Program Supervisor Date <br />YEyS NO <br />Cj/ ?