Fillable Printable Form 280-045-000
Fillable Printable Form 280-045-000
Form 280-045-000
F280-045-000 Non-Accredited or Unlicensed Training Provider Application Supplemental Requirements 10-2017 Page 1
WTB Liaison
PO Box 44326
Olympia WA 98504-4326
Non-Accredited or Unlicensed Training Provider
Application Supplemental Requirements
Phone:
Fax:
360-902-4529
360-902-6706
Instructions
Washington State Department of Labor and Industries has established approval criteria for non-accredited and
unlicensed training providers RCW 51.32.090
.
Read the descriptions below and select the option that applies to you. All providers must complete and submit
a Provider Payment Account Application (F248-011-000)
and respond to all or part of the Supplemental
Requirements as indicated below.
If your program is approved by the Washington State Workforce Training and Education
Coordinating Board (WTECB) or a comparable agency in another state (licensure if required
and/or approved to be on the Eligible Training Provider List [ETPL])
You don’t need to complete the rest of this application. Send us a copy of this page showing your
selection along with documentation required below.
Documentation Required:
• Documentation of approval from Washington State Workforce Training and Education
Coordinating Board (WTECB) or comparable agency in your state.
Example: A pharmacy technician training program that is approved to be on the ETPL would not need to
respond to the Supplemental Questions however applicant must
submit documentation of ETPL approval.
If your program is exempt from state regulation
Exemption from state regulation means your program is not required to obtain licensure and doesn’t
appear on the Eligible Training Provider List or an equivalent state-approved list.
Documentation Required:
• Complete Part 1, Part 2, and Part 3.
• You must respond to the Supplemental Questions.
• Provide appropriate documentation or submit a letter of exemption from the appropriate
regulatory agency.
Example: A safety training program that has been exempted from regulation would need to respond to
the Supplemental Requirements attachment and submit a letter of exemption from the appropriate
regulatory agency.
If your program offers courses through a public entity
Documentation Required
• Complete Part 3.
Example: An EXCEL course offered through a city parks department would need to complete Part 3
Supplemental Questionnaire only.
F280-045-000 Non-Accredited or Unlicensed Training Provider Application Supplemental Requirements 10-2017 Page 2
Part 1 – Ownership, Financial, and Business Information
All providers must submit the following documentation:
1. Proof of continuous operation for at least two years prior to the date of this application.
Exception: A program that is part of a publicly funded entity e.g. city, county, or federal is exempt from
the two year requirement.
2. Identification of owners, shareholders, and directors.
a. For all individuals with a 10% or more ownership interest, submit the following:
i. Complete legal name.
ii. Current telephone number.
iii. Current mailing address.
iv. Birth dates.
v. Prior training affiliations.
Not sure what the definition of ownership is? See below.
3. The name, address, and telephone number of the corporation’s registered agent.
4. Financial statement reflecting the financial status at the close of the most recent fiscal year.
5. Financial references.
a. The names of at least one bank or other financial institution and two other entities that the
department may consult as financial references.
b. A written statement authorizing the department to obtain financial information from the
references.
Exception: A program that is part of a publicly funded entity e.g. city, county, or federal is exempt from
the financial disclosure requirements.
For providers in Washington State, provide the following:
1. Master Business License from the Department of Licensing.
2. Charter from the Secretary of the State’s Office if your business is a limited partnership or corporation.
3. Department of Revenue registration.
For providers outside of Washington State, provide the following:
1. A copy of your business license.
Definition of Ownership:
• In the case of a training provider owned by an individual – that individual is the owner.
• In the case of a training provider owned by a partnership – all full, silent, and limited partners having
10% or more ownership interest are the owners.
• In the case of a training provider owned by a corporation – the corporation, each corporate director,
officer, and each shareholder owning shares of issued and outstanding stock aggregating at least 10%
of the total issued and outstanding shares are the owner.
F280-045-000 Non-Accredited or Unlicensed Training Provider Application Supplemental Requirements 10-2017 Page 3
Part 2 – Training Program Information
Please submit the following:
1. A copy of the training provider’s catalog.
2. A copy of the training provider’s enrollment agreement/contact. Include the following:
a. The number of clock hours of instructions.
b. The method of instruction (e.g. correspondence, classroom, lab, computer assisted).
c. The average length of time required for successful completion.
3. If the instruction is calculated in credit hours, provide the following:
a. A description of the contact hour formula applied by the training provider for example the
number of contact hours applicable to each quarter or semester credit hour of lecture,
laboratory/practicum, and/or internship/externship.
b. For distance education training providers, the instructional sequences as described in the
number of lessons.
Distance education means education provided by written correspondence or any electronic
medium for students who are enrolled in a private vocational school in pursuit of an identified
occupational objective, but are not attending classes at an approved site or training
establishment.
4. A document outlining the scope and sequence of courses or programs required to achieve the
educational objective.
5. A copy of the training provider’s admission procedures, including policies describing all prerequisites
needed by entering students to successfully complete the programs of study.
6. Documentation indicating the total cost of training for each program, including:
a. Registration fees, if any
b. Tuition
c. Books
d. Supplies
e. Equipment
f. Laboratory usage
g. Special clothing
h. Student activities
i. Insurance
j. All other charges and expenses necessary for the completion of the program
7. A copy of the training provider’s cancellation and refund policy including:
a. Cancellation before the training start date.
b. Cancellation within 30 days of the start date.
c. Interruptions in service due staffing or other reasons.
F280-045-000 Non-Accredited or Unlicensed Training Provider Application Supplemental Requirements 10-2017 Page 4
Part 2 – Training Program Information (Continued)
8. The training calendar including:
a. Hours of operation
b. Holidays
c. Enrollment periods
d. The start and end dates of the term, courses, or programs
9. An accurate description of the following:
a. The training provider’s facilities and equipment available for student use
b. The maximum or usual class size
c. The average student/teacher ratio
10. The names and qualification of faculty.
11. A copy of the training provider’s policy on standards of progress required including:
a. A definition of the grading system
b. The minimum grades considered satisfactory
c. Conditions for interruption for unsatisfactory progress
d. A description of the probationary period, if any, allowed by the training provider
e. Conditions for re-entrance for students dismissed for unsatisfactory progress
f. A statement that a progress report will be given to the student
12. The training provider’s policy towards student conduct, including causes for dismissal and conditions for
re-admission.
13. The training provider’s policy on the following:
a. Leave
b. Absences
c. Class cuts
d. Makeup work
e. Tardiness
f. Interruptions for unsatisfactory attendance
Training providers that prepare students for obtaining employment must submit the following:
1. Documentation of the training provider’s completion rate and job placement rate – including the title,
wages, and benefits obtained by graduates.
2. Documentation to address the following:
a. Whether any of the training provider’s programs allow a student to obtain an educational or
occupational credential awarded upon successful completion of program, and if so, the type of
credential(s) awarded.
b. Whether any of the training provider’s programs have clearly identified program objectives, such
as information regarding specific job titles the student will qualify for on completion of training,
and the projected wages and benefits of those jobs.
c. Training provider’s job placement rate including job title, wages, and benefits obtained by
graduates.
d. Whether the program achieved at least a 30% completion rate and a 50% job placement rate in
the three quarters following graduation for the most recent fiscal year.
F280-045-000 Non-Accredited or Unlicensed Training Provider Application Supplemental Requirements 10-2017 Page 5
Part C. Supplemental Questionnaire
Labor and Industries will also consider the answers to the following questions when deciding whether
to approve a non-accredited or unlicensed training provider for Washington injured workers.
Are there quality assurance guidelines for ensuring that instructors are qualified and adequately supervised to
provide appropriate training and instruction?
No Yes
If yes, please explain below:
Have any students been injured as a result of failure to use adequate safety protocols?
No Yes
If yes, please explain below:
Have any complaints been filed by current or former students against the training provider or any of its
instructors? No
Yes
If yes, please explain.
Have any instructors ever been convicted of a crime?
No Yes
If yes, please explain the nature of the crime.
Provider's Statement of Agreement (please print or type)
I,
,verify these answers are true to the best of my knowledge.
I understand false information could result in the termination of an L&I provider payment number.
Signature
Title
Date
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