New Worksite/WEX Order Form

New Worksite/WEX Order Form

Please complete all the fields. If you need guidance, please ask your DPI Staffing representative.
Please click here to access all DPI/Worksystems resources and forms.
WORKSYSTEMS

ID: 1607594

CODE: 36
Date:*

MonthDayYear
(defaults to today's date)
Liaison Name: *
Liaison Email Address:*
example@example.com
Contracted Service Provider*
WORK EXPERIENCE INFORMATION
Worksite Name:*
Is this for a YOUTH or ADULT Work Experience?*

YouthAdult
Worksite Name: *
Worksite Name should exactly match the Position/Job Description and should be either identical to the Worksite Operator on the WSA or, if more than one site, a combination of the exact Worksite Operator name and the site name listed in the Worksite Address field from Exhibit B (e.g.: “ABC Company – Downtown”)
Worksite Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Worksite Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Timesheet Approver Name: *

First NameLast Name
Is Timesheet Approver phone number the same as the worksite phone number?

YesNo
Timesheet Approver Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Timesheet Approver Email:*
example@example.com
New Work Experience (WEX) Title:*
Type of Position: *
For workers' compensation purposes. "Clerical" refers to typically administrative/office roles. Everything else should be designated "non-clerical."
Participant Hourly Pay Rate:*
Anticipated Start Date:*

MonthDayYear
Date
Worksite Agreement End Date: *

MonthDayYear
Date
This Work Experience provides constant supervision of Participant(s):*

YesNoOther (please explain)
Does this position work in an agricultural/farm environment?

YesNo
The DOL requires all agricultural positions register with their agency via the WH-535 form, that requires a fingerprint card for the worker(s). Please reach out to DPI (503.281.1285) or to worksystems@dpistaffing.com to help coordinate this endeavor.
Upload Job Description:*

Cancelof
Background Check Requirements*

No DPI background checkBackground clearBackground non-prohibitiveBackground check will be conducted outside of DPICustomer specific
The basic background prohibitions for DPI employees are:
- Any conviction for the attempt or commission of a violent crime, including (but not limited to) sex crimes (excluding prostitution), murder, or a crime that resulted in death, no matter when it occurred.
- Open or ongoing cases involving any of the above crimes will prevent an applicant or current employee from being hired or assigned, respectively.
But before making any decisions based on that limited information, please read the full policy.
Specific Background Check Requirements:*
Please note any specific needs, e.g. “no theft in last seven years”
Drug Screening Requirements*

No Drug Screen Required (default)5 panel clear (tests for THC)5 panel clear (not tested for THC)10 panel clear
Certifications Required for this Work Experience:*

Driver's License (standard)CPR/First AidCOVID-19 Vaccination(s)Other Vaccinations (specify below)Food Handler's CardNoneOther:
Type of Vehicle:*

Employee's vehicleCustomer vehicleOther (please describe)
ADDITIONAL STEPS/RESOURCES
Upload the Worksite Agreement: *

Cancelof
Upload the Site Safety Walkthrough/Evaluation

Cancelof
Additional Comments, Clarifications, and/or Information:
If there is absolutely nothing more to include to ensure this job is set up appropriately, please enter "N/A"
Signature

Clear
Admin Notice
example@example.com
Should be Empty:

New Worksite/WEX Order Form

WORK EXPERIENCE INFORMATION

ADDITIONAL STEPS/RESOURCES