Form ETA-9084 Comprehensive Services Quarterly Report

ETA Form 9084 - Comprehensive Services Quarterly Performance Report
OMB No.
Expires:

1205-0422
3/31/2010

A. GRANTEE IDENTIFYING INFORMATION
1. Grantee Name:

2. Grant Number:

3. Program/Project Name:
4. Grantee Address:

5. Report Quarter End Date:

City _________________________

State ______

Performance Items

Zip Code __________
Previous
Quarter
(A)

6. Report Due Date:
Cumulative
4-Qtr Period
(C)

Current
Quarter
(B)

B. CUSTOMER SUMMARY INFORMATION
1. Total Exiters
2. Total Participants Served

School Status

Gender

3. New Participants Served
3a. Male
3b. Female
3c. In-School, H.S. or less
3d. In-School, Post H.S.
3e. Not Attending School; H.S. Graduate
3f. Not Attending School; H.S. Dropout

Other Demographics

3g. Offender/Criminal Justice Barrier
3h. Individuals with a Disability
3i. Public Assistance Recipient
3j. Basic Skills Deficiency
3k. Limited English Proficient
3l. Eligible Veterans
3m. Homeless

C. CUSTOMER SERVICES AND ACTIVITIES
1. Core Services
2. Intensive Services
3. Training Services
3a. Basic Skills or Literacy Activities
3b. Occupational Skills Training
3c. On-the-Job Training
3d. Entrepreneurial and Small Business Training
3e. Other Training Services

D. PERFORMANCE RESULTS (OPTIONAL)
1. Additional Grantee Determined Measure
2. Additional Grantee Determined Measure
3. Additional Grantee Determined Measure

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E. REPORT CERTIFICATION/ADDITIONAL COMMENTS
1. Report Comments/Narrative:

2. Name of Grantee Certifying Official/Title:

3. Telephone Number:

4. Email Address:

Public Burden Statement: This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0422. Persons are
not required to respond to this collection of information unless it displays a currently valid OMB number and expiration date. Public reporting burden for
this collection of information, which is required for obtaining or retaining benefits (PL 105-220, Sec. 166), is estimated to average 24 hours per response,
including time for reviewing instructions, searching existing data sources, gathering and reviewing the collection of information. This is public information
and there is no expectation of confidentiality. The reason for the collection of information is general program oversight, evaluation and performance
assessment. Send comments regarding this burden, to the U.S. Department of Labor, Employment and Training Administration, Indian and Native
American Programs, 200 Constitution Avenue, NW, Room S-4206, Washington, D.C. 20210.
ETA-9084
Rev. July 2009
Previous versions not usable