Form ETA 9149 ETA 9149 Report for Youth Recovery Act Funds with TANF last two c

YOUTH SERVED WITH WIA RECOVERY ACT RESOURCES

MONTHLY REPORT

ETA Form: ETA-9149

Report Due Date: mm/dd/yyyy

OMB No.

1205-0474

Report Month End Date: mm/dd/yyyy

Expires:

1/31/2013

State: ________________________________________

ARRA YOUTH REPORTING

TANF WAIVER REPORTING

Performance Items

Current Month (A)

Program-to-Date (B)

Current Month (C)

Program-to-Date (D)

A. PARTICIPANT SUMMARY INFORMATION

1. Total number of new participants served

2. Total number of participants served

Gender

3a. Male

3b. Female

4. Ethnicity: Hispanic/Latino

Race

5a. American Indian or Alaska Native

5b. Asian

5c. Black or African-American

5d. Hawaiian Native or Other Pacific Islander

5e. White

Education Level

6a. 8th grade and under

6b. 9th grade - 12th grade

6c. High School graduate or equivalent

6d. 1 - 3 years of college, or full-time technical or vocational school

6e. 4 years college or more

School Status

7a. In-school youth

7b. Out-of-school youth

Age

8a. 14 - 18

8b. 19 - 21

8c. 22 - 24

9. Individuals with disabilities

10. Eligible Veterans

11. Number of participants placed in summer employment

12. Number of participants placed in work experiences outside of the summer months

13. Number of participants served receiving educational achievement services

14. Number of participants transitioning into unsubsidized employment

15. Number of participants receiving additional support services for youth

16. Number of participants receiving leadership development opportunities

17. Number of participants receiving follow up services

18. Number of summer employment participants enrolled in services beyond summer employment

Performance Items

Current Month (A)

Program-to-Date (B)

Current Month (C)

Program-to-Date (D)

Value

Numerator

Value

Numerator

Value

Numerator

Value

Numerator

Denominator

Denominator

Denominator

Denominator

B. LEADING INDICATORS of PERFORMANCE

1. Work Readiness Indicator

2. Summer employment/work experience completion rate

C. REPORT CERTIFICATION/ADDITIONAL COMMENTS

Grantee Remarks:

Name of Grantee Certifying Official:

Telephone Number:

Email:

Public Burden Statement:

This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0474, expiring 01/31/2013. 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 is estimated to average 29 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, Office of Performance and Technology, 200 Constitution Avenue, NW, Room S-5206, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0474).

ETA-9149

REV. 4/2010

Previous versions not usable