Supplemental Data Sheet for Application for Authority to Employ Workers with Disabilities at Subminimum Wages

• Legal Form Number: WH-226A
• Issuer: Wage and Hour Division
• Section: U.S. Department of Labor

WH-226A

Supplemental Data Sheet for Application for

Authority to Employ Workers with Disabilities at

U.S. Department of Labor

Wage and Hour Division

230 S. Dearborn Street, Room 530

Chicago, IL 60604

Subminimum Wages

OMB NO: 1235-0001

Expires: 07-31-2027

For all applicants, this form should be submitted with the Application for Authority to Employ Workers with Disabilities at Subminimum

Wages (WH-226). A separate WH-226A should be submitted for each of the establishments and work sites counted in Item 6 of the WH-226.

Please do not staple the form or accompanying documents.

Instructions for completing this form are on pages 3-4.

ESTABLISHMENT INFORMATION

1. Name of Establishment / Work Site

2. Address of Establishment / Work Site

3. This Establishment / Work Site is (check one):

Main Establishment (ME) Branch Establishment (BR)

Off-site Work Location (OL) School Work Experience Program Work Site (SWEP)

GOVERNMENT CONTRACTS

Yes No

4. Is Service Contract Act (SCA)-covered work performed at this establishment / work site?

5. Is work performed at this establishment / work site pursuant to a Federal contract for

services or concessions and may be subject to Executive Orders 13658 or 14026 (Minimum

Wage for Contractors)?

Yes No

EMPLOYEE INFORMATION

6. Enter the total number of employees who were employed at this establishment / work site at any time during the most recently

completed fiscal quarter and received subminimum wages: _______________________

7. (See chart on page 2) Please provide the requested information for all employees with disabilities paid subminimum wages

during the employer’s most recently completed fiscal quarter who were counted in Item 6 (above). Attach additional sheets, as

necessary. Note: See pages 3-4 for detailed instructions and a sample chart.

Form WH-226A

REV 07/2024

Page 1 of 4