5-3202600043 Att 5 Employer Interest Form.pdf

3202600043 Employer Child Care Solutions

Texas Workforce Commission

RFP 3202600043 Employer Child Care Solutions

Attachment 5 Sample Employer Interest Form

Name of Employer/Lead Entity for Consortium of Employers (referred to as “Employer” hereafter):

Employer Mailing Address:

City, State and Zip Code:

Employer Physical Address (if different from mailing address):

City, State and Zip Code:

Telephone: (___)___-___

Website:

Federal Employer Identification Number:

Primary Contact:

Primary Contact Title:

Primary Contact Email:

Primary Contact Telephone:

Has Employer, including the Consortium, conducted an Employee Needs Assessment* within the past twelve (12) months?

Yes No

If yes, when was the Employee Needs Assessment completed? ______

*An assessment of the needs of the local employee community, which must include the following required elements: employee interest and demand, community demand, capacity and areas with the most need for additional child care resources, and the availability of child care in the communities where employees live and work.

If Employer is an Employer with more than one business location in the state of Texas with Texas employees or a Consortium of multiple Employers with Texas employees, and if Employer is requesting Technical Assistance Services for more than one location, complete the following. (Refer to the TWC web page for descriptions of Technical Assistance (TA) Services available under the Employer Child Care Solutions RFP.) Please note that TWC may not permit separate TA Services to an Employer with more than one business location. The decision to grant separate TA Services per location resides solely with TWC.

1. Specify the number of business locations under the Employer or the number of Employers in the Consortium and the physical addresses for each location/Employer.

2. In no more than 1,000 characters, summarize what the Employer or the Consortium is seeking to accomplish, clearly identifying if what is to be accomplished will be identical among the Employer locations or Consortium Employers. If not identical, explain the differences.

TA Provider selected:

How did you learn about this TA Provider?

o Website o TWC Website o TA Provider Website o Contacted by TA Provider o Local Workforce Development Board o Other (Please describe)

In seeking to participate in the TWC Technical Assistance for Employer -

Supported Site-Based Child Care Program (Program) funded by the

Employer Child Care Solutions RFP and to receive Technical Assistance

Services from the selected TA Provider, Employer must agree to certain assurances and attestations.

By signing and submitting this Employer Interest Form, Employer certifies, assures, and attests to the following:

1. Employer certifies, attests, and assures it has employees within the

State of Texas.

2. Employer certifies it is a single Employer or a Consortium of Employers interested in exploring how to meet the child care needs of their employees with children and working within the State of Texas, including the development of Employer-Supported Site-Based Child

Care.

3. Employer attests it has employees employed within the State of Texas and may benefit from the Technical Assistance Services.

4. Employer assures that it is seeking to ascertain its child care needs through the Technical Assistance Services available under the Program and, if applicable, to explore the need for the development of

Employer-Supported Site-Based Child Care. Technical Assistance

Services available under the Program are: Employee Needs

Assessment (required unless one has already been completed within the past twelve (12) months), Employer Feasibility and Cost Analysis

Study, Options Analysis and Recommendations Report, Site Selection

Report and Business Plan. Employer understands no other services performed by a TA Provider will be paid by TWC.

5. Employer certifies that it will not request Technical Assistance Services in this Program that have been or are being performed for Employer within the past twelve (12) months or that Employer has already budgeted for or has paid for with its own funding.

6. Employer attests that it will execute the required TA Provider and

Employer Technical Assistance Services Agreement (“Agreement”) with the selected TA Provider in order to receive the Technical Assistance

Services identified in this Program. This Agreement does not obligate

Employer to pay for the TA Services.

7. Employer attests that it will provide to TWC in writing, within five (5) business days upon receipt of TWC request, the required verifications of each Technical Assistance Service that has been completed to confirm receipt of the final report, study, assessment, or plan in order for TWC to promptly pay the TA Provider. Verification is required from

Employer for each study, report, assessment, or plan. Failure to provide the verifications required may limit Employer’s ability to receive future Technical Assistance Services.

8. Employer attests that it will participate in TWC surveys regarding the quality of TA Provider’s TA Services, as requested. These surveys will not be required for each report, study, assessment, or plan.

9. Employer understands that it may seek additional technical assistance not identified in the Program from the Employer-selected TA Provider or any other TA Provider and that TWC will not be a party to a contract or pay the TA Provider or Employer for any of these additional technical assistance services.

The person signing this Employer Interest Form hereby warrants that he/she has been fully authorized to submit this Form on behalf of Employer.

Name of Signer:

Title and Affiliation:

Signature:

Date: