WNCSB Member File Sample Form

SERVE WISCONSIN AMERICORPS MEMBER FILE CHECKLIST PROGRAM YEAR 2016-2017 Member Name: Type of Slot: FT HT RHT QT MT Agency/Program Name: Name and title of person completing this form:

MEMBER DOCUMENTATION CHECKLIST Member Application Is there an application in the member’s file? Yes No NA - Program uses My AmeriCorps portal application

Member Eligibility Form Is the Member Eligibility Confirmation Form (DOA-14000, long form) complete? Yes No NA - Eligibility determined for prior term of service with same program

If no, what section(s) is not complete? ______

Does the member have a high school diploma or equivalent? Yes No

If no, does the program have documentation that it is helping the member to earn the equivalent of a high school diploma or does the program have an independent evaluation attesting that the member is not capable of earning a diploma or GED? Yes No NA

Criminal History Checks See NSCHC Monitoring Tool

Is the Criminal History Check Procedure Verification Form complete? Yes No

Does the member’s service include activities with recurring access to children (17 or younger), or older persons (age 60 plus), or individuals with disabilities? If yes, then FBI fingerprint check is required. Yes No

Did the program obtain prior, written authorization from the individual for the State registry check, for the FBI criminal history check, and for the appropriate sharing of the results of the checks within the program? Yes No Comments: ______

In selecting or placing the member, did the program review and consider the background check results? Yes No (See Criminal History Check Procedure Verification Form)

Was a National Sex Offender Public Website (NSOPW) check completed? Yes No Date completed: ______

Was a Wisconsin state criminal history registry check completed? Yes No Date completed: ______

Was the member residing in another state (not Wisconsin) at the time of application? Yes No If yes, list the state of residence: ______If yes, was a state criminal history registry check completed for the state the member was residing in at time of application? Yes No NA Date completed: ______

Was an FBI fingerprint check completed? Yes No NA AmeriCorps Member File Checklist 2016-2017 Page 2

Date completed: ______

Was a Wisconsin Circuit Court Access (WCCA) check completed? Yes No Date completed: ______

Member Enrollment Forms My AmeriCorps Portal Enrollment Form Was the enrollment form completed in the My AmeriCorps portal within 30 days of the date of enrollment? Yes No NA

Does the member file have a copy of the handwritten National Service Trust Enrollment Form signed by the member and program staff as documentation of the member’s enrollment information that was entered into the portal by program staff? Yes No NA Signature date(s) on handwritten enrollment form: ______NA

Date of enrollment listed in the My AmeriCorps portal: ______NA

Signature date(s) on handwritten form is/are on or before date of enrollment listed in the My AmeriCorps portal? Yes No NA

Does the date of enrollment in the My AmeriCorps portal match the enrollment date in OnCorps? [The enrollment/start date in OnCorps is available from the program’s Individual Member Reports page.] Yes No

Comments______

Member Contract Is there a member contract in the file? Yes No Is the contract signed and dated by the member? Yes No Is the contract signed and dated by the program? Yes No Is the contract signed and dated on or before the member start date? Yes No If the member is under 18 years old, is the contract signed by a parent or guardian? Yes No NA

Does the contract specify the amount of living allowance the member will receive? Yes No

Does the contract specify the correct education award amount the member is eligible to earn? Yes No 16-17: FT - $5,775; HT - $2,887.50; RHT - $2,199.92; QT - $1,527.45; MT - $1,221.96

Comments______

Member Position Description Is there a member position description in the file? Yes No

AmeriCorps Member Position Title: ______

Are the activities allowable and linked to the program’s focus? Yes No

Comments______

Publicity Release Form AmeriCorps Member File Checklist 2016-2017 Page 3

Is there a completed/signed Publicity Release Form in the file? Yes No If the member is under 18 years old, is the publicity release form signed by a parent or guardian? Yes No NA

Health Care (Not applicable to EAP & Professional Corps program) Is the member serving in a full-time slot? Yes No NA

If the member requested health care coverage, at the time of enrollment, was the full-time member covered by another health care policy? Yes No NA

Did the full-time member request health care coverage? Yes No NA

Did the member waive health care coverage? Yes No NA

Is a waiver included in the member’s file? Yes No NA

Child Care

Is the member serving in a full-time slot? Yes No NA

Is the full-time member receiving child care subsidies from another source during his/her term of service? Yes No NA

Was the member offered child care? Yes No NA

Did the member request child care? Yes No NA

Did the member waive the child care benefit? Yes No NA

Is a waiver included in the member file? Yes No NA

If the member requested health care and/or child care assistance and has been reduced to less than full- time status, been exited, or been suspended for a lengthy time period, is there documentation showing that the program contacted the health care and/or child care provider about the member’s change in status/eligibility for the benefit? A temporarily suspended member may receive up to 12 weeks of continued child care benefits if the suspension is: not for cause and/or other disciplinary actions; the member intends to return to service; and the member certifies he/she needs the continued benefit in order to return to service. Yes No NA Comments ______

Performance Evaluations Is there a mid-term evaluation in the file? Yes No NA (Mid-term evaluation is not required for less than 900-hour slots.)

Is there an end-of-term evaluation in the file? Yes No NA

Member Timesheets AmeriCorps Member File Checklist 2016-2017 Page 4

Are the timesheets up to date in OnCorps? Yes No [Check the Member Total Hours by Date roster from OnCorps and view the Program Director’s Notifications page in OnCorps.]

If no, which timesheets are missing?

Are the timesheets approved by a supervisor (there is not an excessive number of hours pending approval)? Yes No If no, which timesheets are not approved?

Other issues with timesheets (e.g., hours before start date, excessive number of hours on a single day without adequate description of activities, etc.) [Reviewed all OnCorps timesheets for this member ]:

Exit/End-of-Term Forms My AmeriCorps Portal Exit Form Was the exit form completed in the My AmeriCorps portal within 30 days of the date of exit? Yes No NA

Does the member file have a copy of a handwritten exit form signed by the member and program staff as documentation of the member’s exit information that was entered into the portal by program staff? Yes No NA Date of exit on handwritten exit form: ______NA Date of exit listed in the My AmeriCorps portal: ______NA Is the date of exit on the exit form the same as the date of exit in the portal? Yes No NA

Does the date of exit in the My AmeriCorps portal match the exit date in OnCorps? [The exit date in OnCorps is available from the program’s Individual Member Reports page]. Yes No NA

Comments______

Was the member exited early? Yes No If yes, does the program have documentation in the member file? Yes No If yes, describe documentation; if no, why not?

Additional WNCSB Guidance/Requirements

 Official Guidance Memo – Employment as a Compelling Personal Circumst. 2-25-11 NA Was the member released for compelling personal circumstance for reasons of employment? Yes No

Did the program consult with a WNCSB program officer prior to decision? Yes No

If yes, does the program have a signed document from the member outlining the items in the February 25, 2011 guidance memo? Yes No

 Official Guidance Memo – Youth Corps Two Consecutive Terms/Same Program Year 12-15-10 NA Did the member serve two terms in the same program year? Yes No AmeriCorps Member File Checklist 2016-2017 Page 5

Did the program consult with a WNCSB program officer prior to enrolling the individual in a second term of service in the same program year? Yes No

Does the program have a signed document from the member outlining the items in the December 15, 2010 guidance memo? Yes No

 Official Guidance Memo – Youth Corps Enrolling 16-year-olds 8-23-02 NA Was the member 16-years-old when enrolled? Yes No

If yes, did the program confirm that the individual was out-of-school at the time he or she began serving by obtaining documentation from the local school district as outlined in the August 23, 2002 guidance memo? Yes No

 Official Guidance Memo – Youth Corps Use of Quarter Time and Minimum Time Slots 8-23-02 NA Was the member enrolled in a 300-hour or 450-hour slot? Yes No

Was the member enrolled in the final three months of the program year? Yes No

If the member was not enrolled in the final three months of the program year, did the member participate in a school or training program that continued to provide services during and/or after the completion of the 300-hour or 450-hour slot? Yes No

 Youth Corps CPR/First Aid Training NA

Does the member’s file have a certificate or completed Serve Wisconsin Youth Corps First Aid/CPR Training Verification Form showing completion of CPR/First Aid training? Yes No

Additional information or comments: