Free 47579.pdf - Indiana

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REPORT OF JOB PLACEMENT IMPACT Service Provider
State Form 47579 (9-96) / IMP 0013

Name of Service Provider

Agreement number

County

Name of Contact

Telephone number of Contact

Date (month, year)

A/F * PROGRAM TYPE

NAME OF CLIENT

SOCIAL SECURITY NUMBER

NAME OF EMPLOYER

POSITION

DATE BEGAN

WAGE PER HOUR

HEALTH BENEFITS Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No Accepted Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No

* TYPE:

P = Placement / IMPACT Standard;

O = OJT;

I = Interim Employment;

G = Grant Diversion