| Name of worker |
How many jobs did this worker perform at this work site? |
Average # of hours worked per week on all jobs at this work site |
Average earnings per hour for all jobs at this work site |
Type of work performed (for employees working more than one job, use job employee worked most hours at subminimum wage) |
Primary disability that affects productivity for job described in (e). Pick only one: IDD; PD; VI; HI; SA; NM; AR; or OT (if OT, specify). See instructions for list of primary disabilities. |
Primary disability: If other, specify |
Prevailing wage rate for job described in (e) |
Productivity measure/ rating for job described in (e) |
Commensurate wage rate/ average earnings per hour for job described in (e) |
Total hours worked for job described in (e) |
Does worker perform work for this employer at any other work site? (yes/ no) |