Page 681

AGENCY RESPONSIBILITIES ________________________________________________________________________________________________ ________________________________________________________________________________________________

PARTICIPANT RESPONSIBLITIES FOR CURRENT COMPONENT ASSIGNMENT(S)

☐ FOR ALL PARTICIPANTS I understand that I am responsible for keeping the agency informed of my progress and needs. I agree to call my Employment Services Worker (ESW) if I have a problem that makes it impossible to keep an appointment or if I wish to discuss or change an activity. I agree to continue in my current activity until I have discussed any problem I may have with my ESW. I will notify my ESW of any changes in my employment status (such as obtaining new employment). I will inform my child care worker of any changes that affect my current activity.

☐ [VIEW Only] I understand that if I fail to participate without a good reason, my TANF benefits/support services will be stopped and my SNAP benefits may be affected.

☐ FOR PARTICIPANTS WHO ARE EMPLOYED I will contact the Employment Services Worker (ESW) to discuss any problems that may affect my employment. I will not quit my job or put myself in a position to be fired without discussing the situation with my worker. I will notify my ESW of any changes in my employment status (such as obtaining new employment or changing jobs). I will complete the required monthly follow-up contact (by phone or by mail) with my ESW prior to the 5th of each month.

☐ FOR PARTICIPANTS ASSIGNED TO JOB SEARCH AND SUPERVISED JOB SEARCH I will carry out the responsibilities as agreed upon on my Job Search form.

☐ FOR PARTICIPANTS ASSIGNED TO CWEP, PSP or WE I will carry out the responsibilities as agreed to on my Work Site Position form. I will make sure that my Supervisor has provided the Attendance/ Performance Rating Sheet to my ESW by the 5th of each month.

☐ FOR PARTICIPANTS ASSIGNED TO EDUCATIONAL OR TRAINING ACTIVITIES I will provide the Attendance Sheet to my ESW by the 5th of each month. I will provide a copy of my grades at the end of each semester/ quarter/activity.

☐ FOR PARTICIPANTS ASSIGNED TO THE FULL EMPLOYMENT (FEP) PROGRAM (VIEW only) I understand that I will receive monthly TANF benefits while I am employed in a FEP placement. I will call my FEP placement supervisor and my worker if I will be absent from work.

☐ FOR PARTICIPANTS ASSIGNED TO PENDING I understand that I am not actively participating at this time, but that the months during which I am assigned to this component will count toward my two year time period. I also understand that I must keep all appointments and answer all calls and letters from agency staff since I may be required to participate in the future.

☐ FOR PARTICIPANTS ASSIGNED TO INACTIVE I understand that I will not actively participate at this time. I also understand that I must keep all appointments and answer all calls and letters from agency staff since I may be required to participate in the future.

☐ FOR PARTICIPANTS ASSIGNED TO VTP (VIEW only) I will complete the 6 month job follow-up and return the verification of my employment to my ESW by ____________ .

☐ ADDITIONAL PARTICIPANT RESPONSIBILITIES NOT LISTED ABOVE ________________________________________________________________________________________________ ________________________________________________________________________________________________

☐ EXCHANGE OF INFORMATION CONSENT (ALL PARTICIPANTS) I understand that my worker may contact employers, service agencies, and others to assist me in connection with my assignments. By signing this form, I give permission to my ESW to share information from my case record when necessary to provide or coordinate services on my behalf.

PARTICIPANT'S SIGNATURE ______________________________________ DATE ____________________ WORKER’S SIGNATURE __________________________________________ PHONE __________________ 032-02-1000-13-eng