Form BIA 8205			U. S. DEPARTMENT OF THE INTERIOR			OMB No. 1076-0062
Rev 01/2004				BUREAU OF INDIAN AFFAIRS				Exp. Date08/31/2007
Burden: 30 Minutes
	APPLICATION FOR JOB PLACEMENT AND/OR TRAINING ASSISTANCE

INFORMATION RECORD                                                                                                Social Security No.         -           -           

Name ( Last, First, Middle Initial )

	
Mailing Address:

	
Date of Birth:

Telephone No. (      )  	

Veteran
       Yes
       No	
Marital Status                  Widowed
          Married                     Single
          Separated                  Divorced	
___Others in Household, non-dependent
Explain:	
Number of Dependents
Dependents                        
Children in School           	

Services Applying for:
  ____Job Placement (JP)
  ____Job Training    (JT)      
  ____Other 
	
Request      (Circle)
   Initial       
   JP Repeat     1     2    3      JT Repeat     1     2	In Case of Emergency
Name:                                                  
Address:                                              
                                                             
Telephone No.                                  	

Education:
Highest Grade Completed:              Schools attended and Date(s):                                                                                                                                                                                                                                                                                                                                                         	

Type of Training or kind of Job you are interested in:                                                                                                                                     
Do You have any physical limitations that would interfere with your training or employment?    Yes            No      
If yes, please explain                                                                                                                                                                                           
Training or Job Location Desired:                                                                                              
For Training:
    Course No. And Title:                                                                                                                           
    School and Address:                                                                                                                                                                                        
Do you have income from any source?   Yes        No       If yes, please explain                                                                                                

EMPLOYMENT RECORD: (List your three most important periods of employment, starting with the most recent.)

From:               To:             Employer Name and Address:                                                                                                              
Job Title:                                 Description of Duties:                                                                                                                     
                                                                                                                                                                                                         
Reason for Leaving:                                                                                                                              

From:               To:             Employer Name and Address:                                                                                                              
Job Title:                                 Description of Duties:                                                                                                                     
                                                                                                                                                                                                         
Reason for Leaving:                                                                                                                              

From:               To:             Employer Name and Address:                                                                                                              
Job Title:                                 Description of Duties:                                                                                                                     
                                                                                                                                                                                                         
Reason for Leaving:                                                                                                                              

Form BIA 8205			U. S. DEPARTMENT OF THE INTERIOR			OMB No. 1076-0062
Rev. 01/2004			BUREAU OF INDIAN AFFAIRS					Exp. Date   08/31/2007
Page 2						Burden: 30 Minutes
TO BE INITIALED BY APPLICANT FOR TRAINING ONLY:
I hereby apply to attend the school indicated on this application and agree to follow all rules, regulations and attendance requirements of the school and to the best of my ability will satisfactorily complete the course, which I have selected.  I further agree that the funds issued me for training purposes by the Bureau of Indian Affairs will be so used or repayment will be made to the U. S. Government.  I understand that if I am eligible for other training funds, such as PELL Grant, etc., this will be included when computing my financial aid package and I agree to use those funds for the purpose intended.  I authorize the school to release grade, attendance, and income information to the Bureau of Indian Affairs’ personnel.                      (Initial)

PAPERWORK REDUCTION ACT AND PRIVACY ACT STATEMENT:
Paperwork Reduction Act Notice of 1995 (5 C.F.R. Part 1320): This information is being collected to determine the eligibility for Job Placement & Training services.  Response to this request is required to obtain financial assistance.  An agency may not collect or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  The control Number for this collection is 1076-0062.
Burden Estimate Statement: Public reporting burden for this form is estimated to average 30 minutes per response.  Send comments regarding the burden estimate or aspects such as utility of information or relatedness to mission of BIA, to Information Collection Clearance Officer, BIA; 625 Herndon Parkway, Herndon, VA 20171.
1.	The authority for solicitation of the information on this form is 25 U.S.C. 13 (42 Stat. 208) and P.L. 84-959 (70 Stat. 986) as amended by P.L. 88-230 (77 Stat. 471, 25 U.S.C. 309)
2.	Disclosure of the requested information by the applicant is voluntary, but required to obtain a benefit.
3.	The purpose of this information collection is to determine your eligibility for services.
4.	The routine use of this information by the BIA and school counselors is to evaluate your request and to assist you before and during your Job Placement & Training activities.  After completion of Training, or a Job Placement, parts or all of the information in your application will be provided to employers who are considering you for employment.  The application will be used in a routine manner by counselors working with you who need background information, and by those persons involved in financial control who need budgeting information contained in the application.
5.	Failure to provide requested information may result in a delay (or denial) in receiving the training or job placement assistance you are seeking.
I have read the above statement.  I hereby provide the required information and authorize the use of such information to the extent of the uses specified in the statement.

                                                                                   				______________________________________________                                                                                    
(Applicant’s Signature)                           (Date) 				(Interviewer’s Signature)                           (Date)      

FOR AGENCY USE
I certify that                                                                                                    Is                         Degree of Indian blood, and a member of the                                                                 ________________________________Tribe and is/is not eligible for training or job placement services.  Individual is serviced by (                         Agency) of (                        Region).
Recommended by:                                                          	 		           Approved:___________ _________________________      Title________                                                                 			                                       (Agency Superintendent)

If required, Regional Action taken:		Approved              	Disapproved               		Date:_________________                                 
                                                                                                                        (Regional Director)__________________________________

DISPOSITION OF THIS CASE:			                                                            Training completed on (date                       )	
Trainee is currently a permanent employee and has remained employed for at least 90 days YES/NO.	
Earnings:  $_____________PRE-Job Placement & Training Service                                  $_____________POST-Job Placement &Training Service
Upon training completion, Trainee received; ___Certificate, ___Degree(2yr)                   
__Trainee dropped out (reason):	

Case worker’s Signature and Date

Ruth Solomon, our responses are italicized. 
1.	The common performance measures for adult training programs as specified by OMB Director’s Memo M-02-06 include earnings in the first quarter as well as earnings in the third quarter after completion of the training program.  Can this information be collected (recommend adding in the Disposition of this Case section, in the For Agency Use Only Part)? 
 The form says annual report because that is the standard the White House insisted on for grants.  Also, it is handled that way in 477 for consistency.  Aside from that, often the jobs they train for are “seasonal” so may have first quarter but not third quarter; annual captures what is available.  The White House also will only use statistics from the state employment offices.

 2.	Recommend rephrasing the last sentence in the Disposition of the Case section to read: “Upon training completion, Trainee received --- Certificate, ---Degree (2yr/4yr/Graduate) etc.  The program is limited to 2 years or less, so no rational for 4yr or graduate.

On application itself:

1.	Why is there a question about “other” marital status?  What would BIA expect for “other”?  Why does the applicant need to explain this?    
We changed that to show others in household who are not dependents; those would be expected to help with living expenses.

2.	In the “Services applying for” block, recommend deleting the question mark after “other?” and providing a line to fill in what other service/s the applicant is applying for.
Some of the information will be gathered from the applicant based on answers provided. Also, in talking to the intake worker, applicant can be advised of services not aware of before, such as child care.  If this is a 2 page, one-sided form, we could direct them to write on the back.

3.	Is the applicant expected to fill in which “Agency” and “Region” is involved here?  Could this cell be moved to the “For Agency Use” part and be filled in by the agency?  
See change made; we put in a sentence in “For Agency Only” and removed that cell, giving more space to the others.

4.	Under Education and Employment Record, could there be an instruction to begin with the most recent schooling/employment?
We added a phrase asking them to start with the most recent of their three important jobs; this gives them a chance to pick out the jobs that are of value in developing a training plan for them. 

5.	Recommend providing blank lines in all of the cells to make it easier for the applicants to fill in the needed information.
It would be easy to create a really messy form unless it were never reproduced; i.e., printed off the computer each time.  That is highly unlikely.  Here, again, if form is not printed back to back with instructions on reverse, the back of the form could be used.