TEST ACF – Workforce Investment Solutions

Application Form

Step 1 of 4

Consent Form

In compliance with the Family Educational Rights and Privacy Act (FERPA) and the Workforce Innovation & Opportunity Act of 2014, Workforce Investment Solutions, as the administrative entity of Title I funds, is responsible for the security and maintenance of customer records and educational records and for monitoring release of information related to those records. It is understood that the information shared between staff from any organization or agency is confidential in its nature and is used solely for the purpose of providing high quality services to you as a customer. It is further understood by the staff, who will be working with you, that they are responsible for maintaining the highest standards as described in FERPA and WIOA in accessing and using customer records in the daily operation of the One Stop Center. Records are to be maintained in a confidential manner, away from access from non-personnel who may be in the Center as a visitor, a customer, or for any other purpose. I understand that Workforce Investment Solutions will need information about my employment in order to provide outcome information for this federally funded program. At a minimum, we will need the following information regarding current, past, and future employment: date of hire, employer’s name, address, phone, job title, job description, work hours, salary, fringe benefits, and supervisor’s name. In addition, copies of pay stubs may be required. Authorization for Disclosure of Information (Initial Each Statement)

I authorize the release of records and information to other agencies and/or individuals by Local Workforce Area 19 as necessary to enhance or develop my employability skills. I understand staff will contact former employers and/or other agencies to verify information I provide.

I give my consent for institutions and/or other agencies to release information regarding my academic progress, testing results, and any other pertinent information that would be relevant to my educational process.

I have received the orientation to the Workforce Innovation & Opportunity Act of 2014, rights and responsibilities’ including Equal Opportunity is the Law and grievance/hearing procedures.

I understand that I may be contacted for a follow-up survey within 1 year after I enter employment. I also understand that customer satisfaction surveys will be conducted and I may be contacted to give feedback as to the services I received.

I understand the Workforce Innovation & Opportunity Act of 2014 is not an entitlement program, and any services or enrollment is contingent upon funding, as well as my adherence to the conditions of the individual performance contract.

I certify that I have read and understood the above description of the disclosure of information. I hereby authorize to provide other agencies with all personal information that has been provided by me, or obtained by any or all partner organizations in meeting my needs as a customer. This consent is granted until such time that I am no longer eligible for services offered through Workforce Investment Solutions.

I have been informed of the employment-related rights and benefits under the Jobs for Veterans Act.

Customer Signature:

Date

Parent/Guardian Signature (if applicable):

Date

Staff Signature:

Date

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