This agreement is between the Department of Social and Health Services (DSHS) and
WORKFARE HOST AGENCY
AGENCY CONTACT’S NAME / PHONE NUMBER (INCLUDE AREA CODE)
AGENCY ADDRESS
A. Purpose
The purpose of this agreement is to set work site standards and procedures for the placement of ABAWDs with the above named Workfare Host Agency to provide meaningful, voluntary work experience to Able-Bodied Adults Without Dependents (ABAWDs) who choose to participate in Workfare to remain eligible for Basic Food benefits (Workfare Participants).
Entity’s Federal Employer Identification Number (FEIN):
Entity type (check the appropriate box):
County City School Federal agency State agency Private non-profit
Public non-profit Indian tribe
Other (specify):
B. Labor & Industries Worker’s Compensation Insurance
DSHS shall pay the cost of worker’s compensation insurance to the Department of Labor and Industries (L&I) for the hours worked by the Workfare Participant. The Department of Labor and Industries does not guarantee that its worker’s compensation coverage provides full immunity from tort claim liability. In any case, DSHS does not assume any liability for any injury to or death of a WorkfareParticipant while on the job.
C. Scope of Agreement
The Workfare Host Agency agrees to:
- Provide Workfare Participants with volunteer work opportunities of up to sixteen hours per month to the extent work is available.
- Review work procedures with the Workfare Participant for a clear understanding of what is expected while doing the volunteer work;
- Not replace existing staff or reduce existing staff hours or pay with volunteer workers;
- Abide by all local, state, and federal regulations including but not limited to non-discrimination and labor rights;
- Complete the Basic Food Workfare Activity Report, DSHS 01-205, to verify the number of hours the Workfare Participant volunteered.
D. Termination and Acceptance of Agreement
This agreement may be terminated by either party upon 30 calendar days advanced written notice to the other party at the email address below.
The signatures below certify that each party has read this agreement, understands it, and accepts the terms and conditions defined in this agreement.
SIGNATURE OF AUTHORIZED WORKFARE HOST AGENCY REPRESENTATIVEDATE / TELEPHONE NUMBER (WITH AREA CODE)
PRINT NAME HERE / TITLE / EMAIL ADDRESS
SIGNATURE OF DSHS REPRESENTATIVEDATE / TELEPHONE NUMBER
PRINT NAME HERE / TITLE / EMAIL ADDRESS
BASIC FOOD VOLUNTEER WORKFARE AGREEMENT
DSHS 09-866 (REV. 02/2016)