Nebraska Department of Transportation

Request for Trainee Approval

Contractor must complete one form for each trainee and submit to:

Highway Civil Rights Office email: NDOT.HCRO-OJT@nebraska.gov

Contractor:	Date Form Completed:
Project No./Name:	NDOT Project Manager:
Site Location:
Trainee’s Direct Supervisor:
Training Program Utilized:
I acknowledge I have been given a copy of the OJT Program that I will be trained on.	Trainee Signature:
Status: Union Apprentice Non-Union Trainee
Trainee’s Name:	Last Four Digits of Trainee’s SSN:	Phone No.:
Gender: Male Female	Disability: Yes No
Race/Ethnicity: Asian Black Caucasian Hispanic Native American Other:
Veteran: Yes No	Previous Training: (If Yes, explain below) Yes No
* If Trainee had previous training, identify when, classification trained for, and number of hours completed:
Classification to be Trained For:	Number of Hours Training to be Provided:
New Hire *Upgrade	Date Hired:
*If Upgrade, Identify Current Classification:	If Upgrade, Identify Current Wage Rate:
Davis-Bacon Wage:	Trainee’s Wage: 1st ½ , 3rd Qtr. , 4th Qtr.
Signature - Contractor’s Representative:
External EEO: Approved *Disapproved	NDOT External Civil Rights Office (Signature):	Date:
*If Disapproved, provide explanation:

NDOT Form 103, March 2023