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Home My WebLink AboutCascade Community Connections Summer Intern - 072825 Docusign Envelope ID:D23BB415-9242-47C1-A7B4-6BF4E6CD55AB DF WASHINGTON go w r sr Utrwe i Mtry I ur SOCIAL AND HEALTH SERVICES `oepartmentofSocial DIVISION OF VOCATIONAL REHABILITATION I a Health Servk6 Pre-Employment Transition Services Transforming fives Group Setting: Work-Based Learning (WBL) Agreement This form outlines the WBL duties, wages/salary, expected schedule, contact information and the terms of DVR reimbursement for the host employer. STUDENT NAME Thailer Houck-Ball ADDRESS CITY STATE ZIP CODE 30 Gene St Chimacum WA 98325 TELEPHONE HOME CELL EMAIL ADDRESS (360)301-2517 jessica20039@yahoo.com EMERGENCY CONTACT NAME TELEPHONE NUMBER Jessica Houck•Be1F 360-301-2517 Work-Based Learning Location WORK-BASED LEARNING JOB TITLE Janitorial Assistant JOB TASKS Vacuuming, cleaning office spaces, garbage, recycling, bathroom cleaning BEGIN DATE END DATE WAGE EXPECTED WORK SCHEDULE(DAYS AND HOURSNVEEK) 07/14/2025 08/29/2025 $ 16.66 /hour M, W, Th 4:30pm-6:30pm Identify accommodations needed to support the WBL: Additional Support and weekly on-site check ins Thailer will also work 6 hours a week due to other commitments throughout the summer. This has been approved by the RTC. _ Employer Information EMPLOYER STUDENT SUPERVISOR Jefferson County Public Health Veronica Shaw ADDRESS STATE ZIP CODE 615 Sheridan St, Port Townsend, WA 98368 TELEPHONE CELL EMAIL ADDRESS 360-385-9400 veronica@co.jefferson.wa.us ACE IT Employment&Transition Services.LLC dba Cascade Community Connections is responsible for paying wages directly to Thailer Houck-Ball (Student) PRE-ETS GROUP SETTING: WORK-BASED LEARNING(WBL)AGREEMENT DSHS 1t-174(07/2022) Page 1 of Docusign Envelope ID:D23BB415-9242-47C1-A7B4-6BF4E6CD55AB Placement S'i U VtN I J IUtN I ItItU UARttK Ur IN I tKhS I Unknown, Open to anything REGIONAL TRANSITION CONSULTANT(RTC)OR DESIGNEE Selma Cunningham or Lori Men Pre-ETS Group Service Provider Information CONTRACTOR/SUBCONTRACTOR BUSINESS NAME ACE IT Employment&Transition Services.LLC dba Cascade Community Connections CONTRACTOR REPRESENTATIVE TELEPHONE NUMBER(WITH AREA CODE) Sam Touchic 360-3]6.6585 JOB-SITE OBSERVATION DAYS/TIMES SITE SUPERVISOR CHECK-IN DAYS/TIMES M,W,Th 4:30pm-6:30pm M,W, Th 4:30pm-6:30pm Student Responsibilities 1. Work the agreed upon WBL schedule and maintain regular attendance; 2. Notify the employer in advance of any absence; 3. Follow supervision of the employer and perform assigned job duties; 4. Work with the Contractor representative assigned to the WBL site 5. Other: Pre-ETS Group Service Contractor Responsibilities 1. Complete necessary paperwork to get students set up as an employee 2. Conduct weekly on-site observations of student to monitor work assignments; 3. Conduct weekly check-ins with on-site supervisor to monitor student progress 4. Maintain accurate student timesheets to include dates and times of hours worked; 5. Pay student wages, payroll taxes, and workers compensation as appropriate and in accordance with Washington State Labor and Industry Standards(if applicable); 6. Identify any reasonable accommodations that may be needed by the student to perform the essential job functions of the WBL, and arrange implementation of accommodations with employer, 7. Submit monthly billing to DVR for student wages: Employer Responsibilities 1. Supervise the student participant as outlined in this agreement; 2. Implement the agreed upon reasonable accommodations; 3. Notify the DVR counselor of any problems or concerns that arise. DATE DVR RTC OR DESIGNEE'S SIGNATURE DATE DVR STUD€NTS SIGNATURE � �� 7/14/2025 �n-c-( >>` r �`" -bill 70e/25 s6,,: ;ONT tE-�'-s;s!GNATURE DATE TSCONTRACTOR'S SIGNATURE DATE �-1' 7. Zg. 2.02-5 sw.ttealikci,Trt tetra- 06/25/2025 PA T/GU DIA 'S SIGN TUBE ID/ATE /�\J �'L:15' Approved as to farm only: - .!' s y - — July 24, 2025 Philip C.Hunsucker, Date Chief Civil Deputy Prosecuting Attorney Jefferson County Washington Page 2 of 2 PRE-ETS GROUP SETTING: WORK-BASED LEARNING(WOL)AGREEMENT DSHS 11474(0772022) 615 Sheridan Street Port Townsend, WA 98368 9eieJson www.JeffersonCountyPublicHealth.org Consent Agenda Public Healt JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENDA REQUEST TO: Board of County Commissioners Josh Peters, County Administrator FROM: Apple Martine, Jefferson County Public Health Director Bonnie Obremski, Intellectual and Developmental Disabilities (IDD) Coordinator DATE: 9uI2 d2--.5, SUBJECT: Benda item — Work-Based Learning Agreement between WA Department of Social & Health Services (DSHS), Jefferson County and Cascade Community Connections for Professional Services to be provided in connection with the provision of a summer internship; July 21, 2025 — August 29, 2025, $0 STATEMENT OF ISSUE: Jefferson County Public Health (JCPH), the Intellectual and Developmental Disabilities program, requests Board approval of an agreement to offer a summer internship to a Jefferson County high school student under the supervision of a Job Coach provided by Cascade Community Connections LLC. Cascade is a provider of services for people experiencing intellectual and/or developmental disabilities in Jefferson County. Internship is for janitorial assistance at JCPH. ANALYSIS/STRATEGIC GOALS/PROS and CONS: JCPH has existing contracts with Cascade Community Connections. The scope of work of those existing agreements does not overlap with the scope of work of this agreement. FISCAL IMPACT/COST BENEFIT ANALYSIS: This is a no-funds-exchanged agreement. Intern will not be a paid by Jefferson County and is not an employee of Jefferson County. Cascade Job Coach will not be paid by Jefferson County and is not an employee of Jefferson County. RECOMMENDATION: JCPH believes authority to sign the DSHS Work-Based Learning Agreement as "Employer"should be delegated to JCPH Deputy Director Veronica Shaw since the contract amount is zero. Please pass a motion to delegate signature authority to Deputy Director Shaw. REVIEWED BY: oCd/Cjej f ore a a tom_ Jos eters, County Administrator Date o`lps Jn� Community Health Er n a lic Health Developmental Disabilities J cyaN 360-385-9444 360-385-9400 (f) 360-379-4487 360-385-9401 (f) Always working for a safer and healthier community DD-25-045 CONTRACT REVIEW FORM Clear Form (INSTRUCTIONS ARE ON THE NEXT PAGE) CONTRACT WITH: Cascade Community Connections Contract No: DD-25-045 Contract For: Summer Intern Term: 7/21/2025 -8/29/2025 COUNTY DEPARTMENT: Public Health Contact Person: Bonnie Obremski Contact Phone: x410 Contact email: bonnieo@co.jefferson.wa.us AMOUNT: -0- PROCESS: — Exempt from Bid Process Revenue: -0- _ Cooperative Purchase Expenditure: -0- _ Competitive Sealed Bid Matching Funds Required: _ Small Works Roster Sources(s)of Matching Funds _ Vendor List Bid Fund # _ RFPorRFQ Munis Org/Obj _Other: APPROVAL STEPS: STEP 1: DEPARTMENT CERTIFIES CO CE 3.55.080 AND CHAPTER 42.23 RCW. I I CERTIFIED: N/A:❑ �� July 24,2025 Signature Date STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE COUNTY (CONTRACTOR) HAS NOT BEEN DEB RRED BY ANY FEDERAL, STATE, OR LOCAL AGENCY. CERTIFIED: El N/A: 11 D/�� July 24,2025 Signatur Date STEP 3: RISK MANAGEMENT REVIEW(will be added electronically through Laserfiche): Electronically approved by Risk Management on 7/24/2025. STEP 4: PROSECUTING ATTORNEY REVIEW(will be added electronically through Laserfiche): Electronically approved as to form by PAO on 7/24/2025. Delete all of the Professional Services Agreement pages. You only need the PRE-ETS GROUP SETTING: WORK-BASED LEARING (WBL) AGREEMENT (2 pages only) STEP 5: DEPARTMENT MAKES REVISIONS & RESUBMITS TO RISK MANAGEMENT AND PROSECUTING ATTORNEY(IF REQUIRED). STEP 6: CONTRACTOR SIGNS STEP 7: SUBMIT TO BOCC FOR APPROVAL 1