On-the-job Training Questionnaire

Keep Illinois Working workshops have been designed to simplify the process of sharing credible information on
current job programs, and then fast-tracking the application process so you receive the benefits ASAP.
In order to help provide this highly efficient and effective service, please type and email this completed form
to keepilworking@gmail.com. A lot of the workshops depend on business owners sending in their completed forms
ahead of time. Once your typed forms are received at keepilworking@gmail.com, your invitation will be emailed to
you, reserving your spot for the workshops.
Thank you.
Name: ___ ___________________________________________________________________________
Name of Business:

______________________________________________________________________

Federal Employment Identification Number (FEIN):_ _______________________________________________

1) Number of years in business _____________________________________________________________
2) Number of full-time employees
_____+
+_____________________________________________________
3) Payroll system used

_____________________________________________________________________

4) Location of payroll records

_______________________________ ______________________________

5) Workers compensation policy

carrier____________________________________________________________
6) Workers compensation policy number
____
___________________________________________________
7) Have you had any On-the-job Training program agreements in the last year (Yes or No)? __________
8) Wages for the position (must be $9.60 or more):
_____________________________________________
9) How many hours per week will they be working?
__________________________________________________
10)
How many people will you need to hire in the next six months?
_____________________________________
11)

Who will be supervising the training and why are they qualified to do so?

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________.