Form ETA-678 Job Corps Placement and Assistance Record

08/28/2007 13:47:01

Page 1 of 1

Career Transition System
JOB CORPS PLACEMENT AND ASSISTANCE RECORD

1. STUDENT ID

2A. LAST NAME

2B. FIRST NAME

5A. STREET ADDRESS

7. DATE OF BIRTH

MO

MO

YEAR

3. SEX

5B. CITY

6. SEPARATION DATE
DAY

2C. MI

8. CENTER ID

9. ASGN

4. PHONE NO.

5C. STATE

10. GED

11. COMPLETION

5D. ZIP CODE

12. GRAD STAT

DAY YEAR

13. STUDENT'S VOCATIONAL TRAINING
A. O*NET Code

Title

B. Training Provider

14. STUDENT'S PLACEMENT STATUS ON DATE THIS FORM COMPLETED
PLACEMENT
STATUS:

01
02
03
04
05

One Full Time Job
Two Full Time Jobs
One Part Time Job
Two Part Time Jobs
Armed Forces

06
07
08
09
10

15. PLACERS ID

Full Time Job/College Combo
Part Time Job/College Combo
High School
Post Secondary School/Training
College

16. Job, SCHOOL, MILITARY OR NOT PLACED INFORMATION (FIRST)
A. Apprenticeship
B. O*NET Code
C. CIP Code
D. Hours
(Job Only)

11
12
13
14
15

OJT/Subsidized Employment
Other Training Program
NP Family Obligations
NP Reentered Job Corps
NP Seeking Placement

E. Hourly Wage

16
17
18
21
22

NP Not Seeking Placement
NP Cannot Locate
NP Other
NP Referred to One-Stop Ctr
NP Referred to other agency

F. Job Title

G. JTM?

17. EMPLOYER, SCHOOL OR INSTITUTIONAL TRAINING PROGRAM (FIRST)
A. Name
B. Number and Street Address

C. City

D. State

E. Zip Code

18. NON-PLACER
A. Was Student Self
Placed ?
F. Area Code & Phone

B. Was Student
Placed By NTC?

19. PLACEMENT VERIFICATION (FIRST)
C. DATE STUDENT REPORTED

A. CONFIRMATION OF PLACEMENT / SELF - EMPLOYMENT STATUS
Name

Title

Phone No.

B. OTHER/COMMENTS

MO

YEAR

D. DATE STUDENT PLACED
MO

20. NAME AND TITLE OF OFFICIAL VERIFYING PLACEMENT (FIRST)

21.SIGNATURE

23. Job, SCHOOL, MILITARY OR NOT PLACED INFORMATION (SECOND)
A. O*NET Code
B. CIP Code
C. Hours
D. Hourly Wage

C. City

D. State

E. Job Title

E. Zip Code

F. JTM?

F. Area Code & Phone

B. Was Student Placed
By NTC?

C. DATE STUDENT REPORTED
Phone No.

B. OTHER/COMMENTS

MO

DAY

YEAR

D. DATE STUDENT PLACED
MO

27. NAME AND TITLE OF OFFICIAL VERIFYING PLACEMENT (SECOND)

YEAR

25. NON-PLACER
A. Was Student Self
Placed ?

26. PLACEMENT VERIFICATION (SECOND)
A. CONFIRMATION OF PLACEMENT / SELF - EMPLOYMENT STATUS
Title

DAY

22. DATE PLACEMENT VERIFIED
MO
DAY
YEAR

24. EMPLOYER, SCHOOL OR INSTITUTIONAL TRAINING PROGRAM (SECOND)
A. Name
B. Number and Street Address

Name

DAY

28.SIGNATURE

DAY

YEAR

29. DATE PLACEMENT VERIFIED
MO
YEAR
DAY

US DEPARTMENT OF LABOR - EMPLOYMENT AND TRAINING ADMINISTRATION OMB CONTROL NUMBER (1205-0035) EXPIRES June 30, 2007

ETA-678