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ICR 200806-1205-007 · OMB 1205-0040 · Object 7530601.
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Document Metadata
| File Type | application/msword |
|---|---|
| File Title | 1 |
| Author | RonS |
| Last Modified By | Writer |
| File Modified | 2007-06-19 |
| File Created | 2026-10-03 |
| Conversion State | complete |
Extracted Text
1. Name of participant___________________ 2. S.S. #
Employer Information
3. Name of employer
4. Employer mailing address
a. Number and street, suite number; and/or PO Box
b. City
c. State d. ZIP code
5. FEIN_____________________________
6. Employer type
Not-for-profit For-profit
Government Self-employment
7. Is employer a host agency? Yes No
8. Did employer provide an OJE training site for this participant? Yes No
9. Employment site name and location________________________________________
9a. *Employer received customer satisfaction survey in PY _________
9b. Employer continued availability Available Not available
*No data entry in SPARQ. Field is system-generated.
Authorized for Local Reproduction ETA-9122
(Revised July 2007)
This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0040, expiring 08/31/2009. Persons are not required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this collection of information is estimated to average twelve (12) minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden; send them to the U.S. Department of Labor, Division of Adult Services, Room S-4203, 200 Constitution Avenue, NW, Washington, DC 20210 (Paperwork Reduction Project 1205-0040).
Contact/Supervisor Information
10. Name of contact person
11. Contact person’s mailing address if different from number 4
__________________________________________________________________________________
a. Organization name or address field 1
__________________________________________________________________________________
b. Number and Street, Suite Number; and/or PO Box or address field 2
__________________________________________________________________________________
c. City
__________________________________________________________________________________
d. State e. ZIP Code
12. Contact person’s title
12a. Contact person’s salutation Mr. Ms.
13. Contact person’s phone number
13a. Contact person’s fax number
13b. Contact person’s e-mail address
Complete fields 13c-13i if supervisor is different from contact person (number 10). If supervisor is the same as contact person, skip to field 14.
13c. Name of supervisor
13d. Supervisor’s mailing address if different from number 4
a. Organization or address field 1
_____________________________________________________________________
b. Number and Street, Suite Number; or PO Box or address field 2
c. City
d. State e. Zip Code
13e. Supervisor’s title
13f. Supervisor’s salutation Mr. Ms.
13g. Supervisor’s phone number
13h. Supervisor’s fax number
13i. Supervisor’s e-mail address
Placement Information
14. Start date_______________________(MM/DD/YYYY)
15. End date_______________________(MM/DD/YYYY)
16. Starting wage per hour $_____________________
17. Benefits (check all that apply)
a. Health insurance
d. Vacation
g. Other__________(specify)
b. Sick leave
e. Transportation
h. None
c. Pension/profit sharing
f. Room and board
18. At time of placement, is employment expected to be full- or part-time?
Full-time Part-time
If part-time, number of hours per week expected
19. Job title
19a. Participant’s job code _________
1. Art, Design, Entertainment, Sports, and Media
8. Food Preparation and Service
15. Production, Assembly, Light Industrial
2. Business and Financial Operations
9. Healthcare
16. Protective Service
3. Community and Social Services
10. Legal
17. Retail, Sales, and Related
4. Computer and Mathematical
11. Maintenance and Custodial
18. Self-Employment
5. Construction, Installation, and Repair
12. Management
19. Transportation and Material Moving
6. Education, Training, and Library
13. Office and Administrative Support
7. Farming, Fishing, and Forestry
14. Personal Care and Service
19b. High-growth placement
1. Automotive
6. Financial Services
11. Retail
2. Advanced Manufacturing
7. Geospatial
12. Transportation
3. Biotechnology
4. Construction
5. Energy
8. Health Care
9. Hospitality
10. Information Technology
13. None
20. Training-related placement? Yes No
21. Was placement the result of a substantial service provided to the employer by the sub-grantee? Yes No
22. Unsubsidized employment comments
Customer Service Survey Information
23. CS survey number 1 Date _____________ (MM/DD/YYYY)
24. CS survey number 2 Date _____________ (MM/DD/YYYY)
25. CS survey number 3 Date _____________ (MM/DD/YYYY)
Follow-up Information
26. *90-day date (MM/DD/YYYY)
27. Has the participant returned to program within the first 90 days after exit?
Yes No
27a. Has the participant re-enrolled in SCSEP within the first 90 days after exit?
Yes No
28. Follow-up 1
a. *Scheduled date____________________ (MM/DD/YYYY)
b. Completed date____________________(MM/DD/YYYY)
c. Any wages for first quarter after exit quarter? Please also indicate method of verification
i. No wages
ii. Yes, in-state UI records only
iii. Yes, out-of-state UI records (WRIS) only
iv. Yes, both in- and out-of-state UI records
v. Yes, other administrative records
vi. Yes, supplemental through case management, participant survey, and/or verification
with the employer
vii. Unable to obtain information
viii. Excluded
29. Follow-up 2
a. *Scheduled date (MM/DD/YYYY)
b. Completed date (MM/DD/YYYY)
c. Any wages for second quarter after exit quarter? Please also indicate method of verification
i. No wages
ii. Yes, in-state UI records only
iii. Yes, out-of-state UI records (WRIS) only
iv. Yes, both in- and out-of-state UI records
v. Yes, other administrative records
vi. Yes, supplemental through case management, participant survey, and/or verification
with the employer
vii. Unable to obtain information
viii. Excluded
*No data entry in SPARQ. Field is system-generated.
d. If yes, earnings for second quarter after exit quarter $__________________
e. Any wages for third quarter after exit quarter? Please also indicate method of verification
i. No wages
ii. Yes, in-state UI records only
iii. Yes, out-of-state UI records (WRIS) only
iv. Yes, both in- and out-of-state UI records
v. Yes, other administrative records
vi. Yes, supplemental through case management, participant survey, and/or verification
with the employer
vii. Unable to obtain information
viii. Excluded
f. If yes, earnings for third quarter after exit quarter $_______________
30. Follow-up 3
a. *Scheduled date____________________ (MM/DD/YYYY)
b. Completed date____________________(MM/DD/YYYY)
c. Any wages for fourth quarter after exit quarter? Please also indicate method of verification
i. No wages
ii. Yes, in-state UI records only
iii. Yes, out-of-state UI records (WRIS) only
iv. Yes, both in- and out-of-state UI records
v. Yes, other administrative records
vi. Yes, supplemental through case management, participant survey, and/or verification
with the employer
vii. Unable to obtain information
viii. Excluded
*No data entry in SPARQ. Field is system-generated.