Physician's Certificate When a female employee applies for pregnancy leave she must provide her supervisor with a certificate from her physician stating that she is pregnant and giving the estimated date of delivery at least two weeks prior to the date she plans to commence the leave. In the case of a female employee who stops working prior to the commencement of her scheduled leave because of a birth, still-birth or miscarriage that happens earlier than the employee was expected to give birth, that employee must, within two weeks of stopping work, give her supervisor:
Temporary Class Certificate of Registration Rate An employee holding a Temporary Class Certificate of Registration upon presenting proof of current General Class Certificate of Registration by the College of Nurses of Ontario shall be given the salary of the registered staff nurse as provided in this Article retroactive to the date of sitting the certification examination or the date of last hire, whichever is later.
CERTIFICATE OF SERVICE I certify that I served a true and correct copy of the foregoing Consent Agreement and Final Order, docket number _CAA-05-2020-0021 manner to the following addressees: , which was filed on June 26, 2020 , in the following Copy by E-mail to Respondent: Xxxxx X. Xxxxxxx c/o: Jeryl Olson xxxxxx@xxxxxxxx.xxx Copy by E-mail to Xxxxxxx X. Xxxxxx Attorney for Complainant: xxxxxx.xxxxxxx@xxx.xxx Copy by E-mail to Xxxxx Xxxxx Attorney for Respondent: xxxxxx@xxxxxxxx.xxx Copy by E-mail to Regional Judicial Officer: Ann Coyle xxxxx.xxx@xxx.xxx Dated: June 26, 2020 XXXXXX XXXXXXXXX XXXXXXXXX Digitally signed by XXXXXX Date: 2020.06.26 12:23:08 -05'00' XxXxxx Xxxxxxxxx Regional Hearing Clerk
Required Forms If subcontractors are used under the contract that has no stated HUB goal, Exhibits X-0, X-0, X-0 and H-6 are required. Exhibits H-1 and H-6 are required if no subcontractors are being used to perform work under this contract. State of Texas HUB Subcontracting Plan Prime Contractor Progress Assessment Report (Exhibit H-6) is required monthly even when no subcontracting activity has occurred. In addition, State of Texas HUB Subcontracting Plan Prime Contractor Progress Assessment Report (Exhibit H-6) should be submitted with the Provider’s invoice. 12/06 HU EXHIBIT H-1 Legacy Contract No. 24-7IDP5006 DocuSign Envelope ID: 8EFE0772-4B8D-4ECA-AFC4-F4778051DC61 PS Contract No. 6388 Texas Department of Transportation Subprovider Monitoring System Commitment Worksheet Contract #:24-7IDP5006 Assigned Goal: 23.7% Federally Funded State Funded X Prime Provider: Halff Associates, Inc. Total Contract Amount: $ 2,000,000 Prime Provider Info: DBE HUB Both _ Vendor ID #: 17513086995 DBE/HUB Expiration Date: N/A (First 11 Digits Only) If no subproviders are used on this contract, please indicate by placing “N/A” on the 1st line under Subproviders. Subprovider(s) (List All) Type of Work Vendor ID # (First 11 Digits Only) D=DBE H=HUB Expiration Date $ Amount or % of Work * AIA Engineers, LTD Utility CM 17606188799 H 2/11/20 8% Xxxxxxxxxx Engineering Corp. Utility Coord. & Utility Engr. 17415546443 N/A -- 8% The Xxxx Group SUE services 18008303275 H D 10/4/17 7/8/17 8% Xxxxxx, LLC Survey Services 17430098982 H D 1/6/17 12/31/16 8% Subprovider(s) Contract or % of Work* Totals 32% *For Work Authorization Contracts, indicate the % of work to be performed by each subprovider. Total DBE or HUB Commitment Dollars $ Total DBE or HUB Commitment Percentages of Contract 24% (Commitment Dollars and Percentages are for Subproviders only) EXHIBIT H-2 Texas Department of Transportation Legacy Contract No. 24-7IDP5006 DocuSign Envelope ID: 8EFE0772-4B8D-4ECA-AFC4-F4778051DC61 PS Contract No. 6388 Subprovider Monitoring System Commitment Agreement This commitment agreement is subject to the award and receipt of a signed contract from the Texas Department of Transportation (TxDOT). NOTE: Exhibit H-2 is required to be attached to each contract that does not include work authorizations. Exhibit H-2 is required to be attached with each work authorization. Exhibit H-2 is also required to be attached to each supplemental work authorization. If DBE/HUB Subproviders are used, the form must be completed and signed. If no DBE/HUB Subproviders are used, indicate with “N/A” on this line: and attach with the work authorization or supplemental work authorization. Contract #: Assigned Goal: % Prime Provider: Work Authorization (WA)#: WA Amount: _ Date: Supplemental Work Authorization (SWA) #: to WA #: Revised WA Amount: SWA Amount: Description of Work (List by category of work or task description. Attach additional pages, if necessary.) Dollar Amount (For each category of work or task description shown.) Total Commitment Amount (Including all additional pages.) $ IMPORTANT: The signatures of the prime and the DBE/HUB and Second Tier Subprovider, if any (both DBE and Non-DBE) and the total commitment amount must always be on the same page. Provider Name: Name: (Please Print) Title: Signature Date Address: Phone # & Fax #: Email: DBE/HUB Sub Provider Name: (Please Print) Title: Signature Date Subprovider Name: VID Number: Address: Phone # & Fax #: Email: Second Tier Sub Provider Name: (Please Print) Title: Signature Date Subprovider Name: VID Number: Address: Phone #& Fax #: Email: VID Number is the Vendor Identification Number issued by the Comptroller. If a firm does not have a VID Number, please enter the owner’s Social Security or their Federal Employee Identification Number (if incorporated). DocuSign Envelope ID: 8EFE0772-4B8D-4ECA-AFC4-F4778051DC61 DocuSign Envelope ID: 84BEDABB-BE5D-4AEF-8367-73737B001986 Legacy Contract No. 24-7IDP5006 PS Contract No. 6388 EXHIBIT H-3 Texas Department of Transportation Subprovider Monitoring System for Federally Funded Contracts Progress Assessment Report for month of (Mo./Yr.) /_ Contract #: Original Contract Amount: Date of Execution: Approved Supplemental Agreements: Prime Provider: Total Contract Amount: Work Authorization No. Work Authorization Amount: If no subproviders are used on this contract, please indicate by placing “N/A” on the 1st line under Subproviders. DBE All Subproviders Category of Work Total Subprovider Amount % Total Contract Amount Amount Paid This Period Amount Paid To Date Subcontract Balance Remaining Fill out Progress Assessment Report with each estimate/invoice submitted, for all subcontracts, and forward as follows: 1 Copy with Invoice - Contract Manager/Managing Office 1 Copy – TxDOT, BOP Office, 000 X. 00xx, Xxxxxx, XX 00000, 000-000-0000, toll free 000-000-0000, or Fax to 000-000-0000 I hereby certify that the above is a true and correct statement of the amounts paid to the firms listed above. Print Name - Company Official /DBE Liaison Officer Signature Phone Date Email Fax EXHIBIT H-4 Texas Department of Transportation Subprovider Monitoring System Final Report Legacy Contract No. 24-7IDP5006 DocuSign Envelope ID: 8EFE0772-4B8D-4ECA-AFC4-F4778051DC61 PS Contract No. 6388 The Final Report Form should be filled out by the Prime Provider and submitted to the Contract Manager and the Business Opportunity Programs Office for review upon completion of the contract. The report should reflect all subcontract activity on the project. The report will aid in expediting the final estimate for payment. If the HUB or DBE goal requirements were not met, documentation supporting good faith efforts must be submitted. DBE Goal: % OR HUB Goal: % Total Contract Amount: $ Total Contract Amount: $ Contract Number: Vendor ID # Subprovider Total $ Amt Paid to Date TOTAL This is to certify that % of the work was completed by the HUB or DBE subproviders as stated above. By: Prime Provider Per: Signature Subscribed and sworn to before me, this day of , 20 Notary Public County My Commission expires: 12/06 DBE-H4.A DocuSign Envelope ID: 8EFE0772-4B8D-4ECA-AFC4-F4778051DC61 WAs Used Contract No. HUB Subcontracting Plan (HSP) Prime Contractor Progress Assessment Report This form must be completed and submitted to the contracting agency each month to document compliance with your HSP. Contract/Requisition Number: Contracting Agency/University Name: Contractor (Company) Name: Point of Contact: Date of Award: Object Code: (mm/dd/yyyy) State of Texas VID #: Phone #: (Agency Use Only) Reporting (Month) Period: Total Amount Paid this Reporting Period to Contractor: $ - Report HUB and Non-HUB subcontractor information *Texas Certified Total Contract $ Total $ Amount Paid Total Contract $ Subcontractor’s VID or HUB HUB? Amount from HSP This Reporting Period to Amount Paid to Date Object Code Subcontractor’s Name Certificate Number (Yes or No) with Subcontractor Subcontractor to Subcontractor (Agency Use Only) $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ TOTALS: $ - $ - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - - $ - Signature: Title: Date: *Note: Prime contractors can verify subcontractor HUB certification status on-line at xxxx://xxx0.xxxx.xxxxx.xx.xx/cmbl/cmblhub.html
Final Certificate, Design Professional’s Certificate of Final Completion The Certificate issued by the Design Professional stating that all work has been completed in accordance with the terms of the Contract Documents. See Section 6,
Medical Certificate Absent from Work (first date of absence) Not absent from work but requires accommodations Part 1 – Employee - please complete following: (Employee Name) The information supplied will be used in a confidential manner and may assist in creating a return to work plan. I hereby consent to the completion of this form by: (Treating Medical Practitioner’s Name) (Signature of Employee) (Date)
