Form WH-226A Supplemental Data Sheet for Application for Authority to

Supplemental Data Sheet for Application for
Authority to Employ Workers with Disabilities
at Special Minimum Wages

U. S. Department of Labor
Wage and Hour Division
Employment Standards Administration
230 South Dearborn Street, Room 514
Chicago, Illinois 60604

_______________________________________________________________________________________________________________________________________________
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB
⏐
OMB No.: 1215-0005
control number.
⏐
Expires:
12/31/2007

Complete this form for every establishment/worksite where you employed workers with disabilities at special minimum wages during your
most recently completed fiscal quarter and submit with the Application for Authority to Employ Workers with Disabilities at Special Minimum
Wages (WH-226). These establishments/worksites must also be listed on Item 6 of the WH-226. See the reverse side for instructions for
completing this form.

1. Name of Worksite:

_______________________________

2. Address of Worksite: _______________________________
_______________________________
_______________________________
_______________________________

3. This worksite is (check one)
_____ ME:
Your Main Establishment
_____ BR:
Branch Establishment
_____ SE:
Supported Employment
Site, including Enclaves
_____ SWEP: School Work
Experience Program Site

4. Enter the ending date of the most recently completed fiscal quarter
for which you are providing information in Items 5 through 9 below:
5. Is SCA work performed at this establishment/worksite?

YES_____

______/______/______
NO_____

Below, list all employees with disabilities paid special minimum wages during your most recently completed fiscal quarter. You
may submit the following information in alternative formats, for example computer printouts, as long as all the requested
information is included. You may attach additional sheets as necessary.

6. Name of Worker with a Disability

7. Primary Disability

10. Enter the total number of unduplicated employees who are
employed at this work site and receive special minimum wages:

8. Type of Work

9. Average
Earnings per Hour

____________

Public Burden Statement
We estimate that it will take an average of 45 minutes per response to complete this collection of information, including time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection information. If you have any comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the U. S. Department of Labor, Administrator, Wage and
Hour Division, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C., 20210 (please do not send the completed form to this address).
WH-226A
January 2002

INSTRUCTIONS FOR COMPLETING FORM WH-226A
Complete this form for every establishment/worksite where you employed workers with disabilities for the work performed at
special minimum wages during your most recently completed fiscal quarter and submit with the Application for Authority to
Employ Workers with Disabilities at Special Minimum Wages (WH-226).
Item 1.

Item 2.
Item 3.

Enter the name of the worksite/establishment covered by this form. Remember that your main establishment is also
considered a worksite if workers with disabilities are employed there at special minimum wages. The
worksite/establishment covered by this form must also appear in either item 2 or item 6 of the WH-226.
Enter the address of the worksite covered by this form. This same address must appear in item 2 or item 6 of the WH226. Remember that a separate WH-226A must be submitted for each worksite/establishment.
Indicate the type of worksite covered by this data sheet.

ME:
BR:

Your Main Establishment. The establishment named in Item 2 of the WH-226.
Branch Establishment. A branch establishment is an establishment or facility operated by the enterprise, that is
physically separate from the main establishment, where workers with disabilities are employed at special minimum
wages.
SE:
Supported Employment Site, including Enclaves. A supported employment work site is a location, outside of the
work center or rehabilitation center, often on the premises of an enterprise separate from the work center or
rehabilitation center, where workers with disabilities paid special minimum wages are placed in employment settings
along with work center staff (job coaches). An enclave is a supported employment work site where a group of
workers with disabilities is working and supervised by staff from the work center.
SWEP: School Work Experience Program Site. A school work experience program (SWEP) site is a workplace in the
community in which a school system has placed a student(s) with disabilities to work in a job(s) at special minimum
wages.
Item 4. Enter the date (month/day/year) your most recently completed fiscal quarter ended. This is the quarter for which you are
providing information in Items 6 through 9.
Item 5. Indicate whether workers with disabilities perform work subject to the Service Contract Act (SCA) at this worksite.
Item 6. Individually list by name all those workers whose disabilities impaired their productive capacity for the work performed
during your most recently completed fiscal quarter and who earned less than the statutory minimum wage or SCA wage
determination rate.
Item 7. Identify the primary disability of each worker identified in Item 6. You may use the codes provided in item 5 of the WH226 or mention the disability by name--for example you could list NM (neuromuscular) or cerebral palsy.
Item 8. Clearly identify the primary type of work performed by each worker with a disability. Possible examples include truck
helper, assembler, janitor, or machine operator.
Item 9. For workers paid hourly wage rates, list the rate or rates paid at the end of the fiscal quarter.
For workers paid by piece rates, list the average earnings per hour. Average earnings are computed by dividing the total
earnings of the individual worker by the number of hours worked during that fiscal quarter. For example: John Jones
earned $900.00 during the quarter ending 6/30/01. He worked 300 hours that quarter, so his average earnings per hour are
$3.00. $3.00 should then be entered in item 9.
The following is an example of how Items 6, 7, 8 and 9 on the WH-226 might be completed:
6. Worker with a Disability

7. Primary Disability

8. Type of Work

9.
Average
Earnings per Hour

John Jones
Robert Smith
Mary Evans

MR
Neuromuscular
Mental Retardation

Assembles bags of bolts
Material Handler
Janitor

$3.00
$3.50
$4.15

Item 10. Enter the total number of employees employed at this work site who are paid special minimum wages. Count each
employee only once. Remember, each of these employees must be reported in items 6 through 9.
The completed WH-226 and all accompanying form(s) WH-226A should be mailed to U. S. Department of Labor, Wage
and Hour Division, Employment Standards Administration, 230 South Dearborn Street, Room 514, Chicago, Illinois
60604.
____________________________________________________________________________________________________________________________________________
WH-226A
January 2002