U.S. Department of Labor
Supplemental Data Sheet for Application for
Wage and Hour Division
230 S. Dearborn Street, Room 514
Authority to Employ Workers with Disabilities at
Chicago, IL 60604
OMB NO: 1235-0001
For all applicants, this form should be submitted with the Application for Authority to Employ Workers with Disabilities at Subminimum Wages
(WH-226). A separate WH-226A should be submitted for each of the establishments and work sites counted in Item 6 of the WH-226.
Instructions for completing this form are on pages 3-4.
1. Name of Establishment / Work Site
2. Address of Establishment / Work Site
3. This Establishment / Work Site is (check one):
Main Establishment (ME)
Branch Establishment (BR)
Off-site Work Location (OL)
School Work Experience Program Work Site (SWEP)
4. Is Service Contract Act (SCA)-covered work performed at this establishment / work site?
5. Is work performed at this establishment / work site pursuant to a Federal contract for
services or concessions that was entered into on or after January 1, 2015, and may be subject
to Executive Order 13658 (Establishing a Minimum Wage for Contractors)?
6. Enter the total number of employees who were employed at this establishment / work site at any time during the most recently
completed fiscal quarter and received subminimum wages: _______________________
7. (See chart on page 2) Please provide the requested information for all employees with disabilities paid subminimum wages during the
employer’s most recently completed fiscal quarter who were counted in Item 6 (above). Attach additional sheets, as necessary.
Note: See pages 3-4 for detailed instructions and a sample chart.
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# of hours
Type of work
Primary disability that
affects productivity for job
jobs worked per per hour employees
described in (e). Pick only
for job rating for job average worked perform
did this week on all for all working more
one: IDD; PD; VI; HI; SA;
described described earnings per for job work
worker jobs at this jobs at than one
NM; AR; or OT (if OT,
in (e) in (e) hour for job described for this
perform work site this work job, use job
specify). See instructions for
described in (e) in (e) employer
at this site employee
list of primary disabilities.
work worked most other work
site? hours at site? (yes/
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INSTRUCTIONS FOR WH-226A SUPPLEMENTAL DATA SHEET FOR APPLICATION FOR AUTHORITY TO EMPLOY WORKERS
WITH DISABILITIES AT SUBMINIMUM WAGES
Initial applicants must submit a WH-226A for each work site counted in Item 6 of the WH-226, including the main establishment. Items 1-5 of the
WH-226A must be completed. Any remaining items on the WH-226A must be completed if the information is available at the time of application.
Renewal applicants must submit a complete WH-226A for each work site counted in Item 6 of the WH-226, including the main establishment.
All items on the WH-226A must be completed.
Provide the name of the establishment / work site covered by this form. Remember that the main establishment is also considered a work site if
workers are employed there at subminimum wages.
Provide the physical address of the establishment / work site.
Indicate whether the work site is the main establishment, a branch establishment, an off-site work location, or a School Work Experience Program
Main Establishment: The primary location of the employer that files this application on behalf of all its associated work sites. (There can only be
one main establishment.)
Branch Establishments: A branch establishment is a physically separate work site that is part of the same organization as the main
Off-site Work Location: An off-site work location is a work site typically on the premises of a separate establishment, where workers with
disabilities, or a group of workers with disabilities, are placed in work settings along with job coaches (staff of the rehabilitation or work center).
School Work Experience Program (SWEP): A school-operated program in which students with disabilities may be placed in jobs with private
industry within the community. School employers are responsible for compliance with all applicable child labor laws, minimum wage standards,
and certificate and recordkeeping requirements. The school may submit a group application which covers all students with disabilities and all of
the business locations at which the students will be placed.
Mark “yes” if the employer has a Service Contract Act (SCA)-covered contract to provide services to the Federal Government and work under that
contract is performed at this work site.
Mark “yes” if the employer has a contract with the Federal Government for services or concessions that was entered into on or after January 1,
2015, which indicates that the contract may be subject to Executive Order 13658 (Establishing a Minimum Wage for Contractors).
Count all employees who were paid subminimum wages and performed work at this work site during the most recently completed fiscal quarter that
ended on the date provided in Item 7(a) of the WH-226. Include workers who were employed for less than the full fiscal quarter, i.e. three-month period.
Provide the following information for every employee counted in Item 7. The employer may use additional pages of this chart, attach a printed
spreadsheet, or submit this information in another format.
(a)Provide the full name of the worker.
(b)If the worker performed more than one job at this work site during the most recently completed fiscal quarter, provide the total number of jobs
(c)Provide the average (mean) number of hours per week the employee worked on all jobs at this work site during the most recently completed
fiscal quarter. Calculate this by taking the total number of hours the employee worked during the most recently completed three-month fiscal
quarter and dividing by the number of weeks in the quarter (13 weeks). For example: 260 hours worked in the quarter ÷ 13 weeks per quarter =
20 hours per week average.
(d)Average earnings are computed by dividing the total earnings of the individual worker by the total number of hours worked during the most
recently completed fiscal quarter. Note: The total number of hours worked should only include the compensable work time (for example, generally
would not include time spent in rehabilitation, therapy, etc.). For example, John Jones earned $900 during the fiscal quarter and he worked 300
hours. $900 ÷ 300 hours = $3.00 per hour, therefore, Mr. Jones’s average earnings per hour are $3.00.
For Items 7(e) – 7(j), provide the following information for the work performed in the most recently completed fiscal quarter. If the worker performed more
than one job at this work site at a subminimum wage, provide the following information for the job for which this worker worked the most number of hours in
the most recently completed fiscal quarter. For example, John Jones performed three jobs over the last quarter: contract for assembling bolts totaling 65
hours, contract for assembling boxes totaling 42 hours, and contract for shredding totaling 25 hours. The employer should provide responses to 7(e) – 7(j)
for Mr. Jones based on his bolt assembly.
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(e)Describe the type of work performed by this worker in the job for which the worker worked the most number of hours at a subminimum wage
rate. Examples may include: sewing, janitorial, box assembly, laundry, etc.
(f)Identify the primary disability that affects the worker’s productivity for the job identified in Item 7(e). Use the following categories:
Intellectual/Developmental Disability (IDD)
Psychiatric Disability (PD)
Visual Impairment (VI)
Hearing Impairment (HI)
Substance Abuse (SA)
Neuromuscular Disability (NM)
Age Related Disability (AR)
Other (OT), Specify
(g)Provide the prevailing wage rate for the job identified in Item 7(e).
(h)Provide the employee’s most recent productivity rating for the job identified in Item 7(e). For work paid hourly, the productivity rating is the
employee’s productivity in proportion to the standard-setter’s that was determined by the employee’s time study. For piece rate work, no
calculation is required, enter “n/a – piece rate”.
(i)For work paid hourly, provide the employee’s commensurate wage rate per hour for the job identified in Item 7(e). This should be the wage
rate actually paid to the worker for this job. For piece rate work, provide the employee’s average earnings per hour for the job identified in
(j)Provide the employee’s total hours worked on the job identified in Item 7(e) over the most recently completed fiscal quarter.
(k)Answer “yes” if the employee also performed work at another work site for which a WH-226A is attached. Include the worker on the
WH-226A corresponding to each work site.
Please see below for an example of how to complete Item 7.
(c) (d) (e) (f) (g) (h) (i) (j) (k)
# of hours
week on all
jobs at this
Type of work
job, use job
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
hour for job
described in (e)
n/a – piece
The completed form WH-226 and all accompanying form(s) WH-226A should be mailed to:
U.S. Department of Labor
Wage and Hour Division
230 South Dearborn Street, Room 514
Chicago, Illinois, 60604
PUBLIC BURDEN STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a
valid OMB control number. The Department of Labor estimates that the public reporting burden for this collection of information will average 120
minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. The obligation to respond to this collection is mandatory in order to obtain the authority to pay
less than the applicable minimum wage. 29 C.F.R. §§ 525.7-9, 12-13. Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the Administrator, Wage and Hour Division, U.S. Department of Labor,
Room S-3502, 200 Constitution Avenue, N.W., Washington, DC 20210 and reference the OMB Control Number.
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