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MIAMI-DADE COUNTY PUBLIC SCHOOLS
Division of Exceptional Student Education ATTACHMENT A
Weekly Contact Log for Supported Employment Job Coaches
Name of Job Coach:
Week of :
Date
Student Name
School
Service
Code
Time
Total
Hours &
Minutes
Location
of Service
Comments
Initials of
Certifying
Personnel
From
To
TOTAL HOURS AND MINUTES
FOR PAGE
CODES
JD - Job Development FU - Follow Up
SS - Student Screening TC - Teacher Consultation
JP - Job Placement RK - Record Keeping
OJT - On the Job Training JCT- Job Coach Travel
1 certify that these
services have been
provided to the above
named students.
Job Coach Signature
Date
Agency Administrator
Date
ESE Dept. Chair/Program Specialist
Date
Student's Employer
Date
SUPPORTED EMPLOYMENT SERVICES FOR THE EDUCATION
OF STUDENTS WITH DISABILITIES
ATTACHMENT B
PROPOSER'S FEE AND CERTIFICATION OF HOURS OF SERVICES
PROPOSER'S FEE
Hourly Fee
LEGAL NAME OF AGENCY OR CONTRACTOR SUBMITTING PROPOSAL:
AUTHORIZED SIGNATURE:
NAME TYPED:
POSITION:
Vendor Information Sheet
1 A.
Federal Employer Identification Number
Or
Owner's Social Security Number
1 B.
Name of Firm, Individual(s), Partners or Corporation
Street Address
City
State Zip Code
3. Ownership Disclosure
ATTACHMENT C
2. Telephone/Fax/Contact Person
Telephone number
Fax number
Contact Person
E-mail address
If the contract or business transaction is with a corporation, partnership, sole proprietorship,or joint venture, the full legal name
and business address shall be provided for the chief officer, director, or owner who holds, directly or indirectly the majority of the
stock or ownership. If the contract or business transaction is with a trust, the full legal name and address shall be provided for
each trustee and each beneficiary. Post Office addresses are not acceptable.
Name
Title
Address
Gender
Race -
ethnicity
Stock Ownership
NOTE: The information provided by the vendor on this form should be consistent with that provided on the "Vendor's
Application". All vendors must have a current vendor's application on file with M-DCPS, and have provided information and/or be
familiar with M-DCPS' policy regarding the following: (a) Employment Disclosure, (b) Drug Free Workplace, (c) Family Leave
Policy, (d) Code of Business Ethics, (e) Conflict of Interest, (f) Perception, (g) Gratuities, and (h) Business Meals. Failure to
provide M-DCPS a current vendor application may cause the vendor not to be awarded anv new business with M-DCPS.
Vendor applications can be downloaded at: http://procurement.dadeschools.net
Occupational Category
AFFIRMATIVE ACTION
EMPLOYMENT BREAKDOWN
Race/Ancestry
ATTACHMENT D
Non- Non- Ain. Ind./
Gender Hispanic Hispanic Alaska
Male Female White Black Hispanic Asian Native
FM-4869 Rev. (O2-01)