Privacy Act Statement

U.S. DEPARTMENT OF LABOR EMPLOYMENT AND TRAINING ADMINISTRATION

SENIOR COMMUNITY SERVICE EMPLOYMENT PROGRAM

PRIVACY ACT STATEMENT

This statement applies to forms used by the Department of Labor for the Senior Community Service Employment Program (SCSEP) that contain confidential data collected from SCSEP applicants and participants. It also describes the collection of this information and how the information will be used.

The Privacy Act of 1974, as amended, requires all Federal agencies, including the Employment and Training Administration (ETA) and its agents, to give the following facts to each person from whom it requests information:

The statutory authority for the request

Why the information is needed

Whether it is voluntary or mandatory to provide the information

The effects of not providing information

The uses which may be made of the information

Whether disclosure of the Social Security Number (SSN) is mandatory or voluntary, by what statute or other authority the number is solicited, and what uses will be made of it

These items are more fully explained in the following sections. If you have any questions about your rights and responsibilities under the Privacy Act, you should ask for assistance from [name of SCSEP provider].

I. The Department of Labor's Authorization to Collect Information

The Employment and Training Administration is an agency of the U.S. Department of Labor. The Department's authority to collect information from SCSEP applicants and participants is found in the Older Americans Act Amendments of 2006, Pub. L 109-365, sections 503(f)(3)-(4). Data collection documents are approved under OMB clearance number 1205-0040, expiring 10/31/2010.

II. Why the information is needed

The SCSEP needs information about age, citizenship, health, employability, behavior, family income, environment, and other matters related to your eligibility, assignment, and progress in the SCSEP. The information may be used to:

Determine whether your training and employment needs can best be met through SCSEP or another program in your home community

Determine whether you meet all eligibility requirements for the SCSEP

Provide a basis for determining your progress in the SCSEP

Maintain a record of wages and other benefits received

III. Obligatory and Voluntary Information and Possible Consequences of Withholding Information or Providing False Information

While there are no penalties under the law for refusing to supply information, the SCSEP requires the collection and maintenance of a wide range of personal information about you, including your Social Security Number, to satisfy enrollment requirements. Not supplying the requested information could delay or prevent you from enrolling and participating in the SCSEP.

The provision of false information by you could lead to expulsion from the program or prosecution under the U.S. Criminal Code when such information is used to support a fraudulent claim to benefits.

IV. How the Information is Used

Your SSN will be used along with other information to identify you as a SCSEP participant and enable [Name of SCSEP provider] to pay you. Only the last four digits of your SSN are displayed in the SCSEP data collection system, and all data are securely encrypted whenever a transmission of files is required for purposes of program management or federal monitoring.

(continued on other side)

In carrying out its responsibility under the OAA to administer the SCSEP program, the Department of Labor must sometimes disclose data from its records about you to another agency or individual without your specific written consent. Such disclosures may be made for the following reasons:

To provide personnel, procurement, or benefit-related information to contractors and agencies to enable them to provide administrative functions for the program, including the maintenance of participant pay records

Disclose to researchers and public interest groups those records that are relevant and necessary to evaluate the effectiveness of the overall program and its various training components in serving different subgroups of the eligible population.

To disclose information to the Office of Management and Budget in connection with its legislative review, coordination, and clearance activities

To provide statistical information to the news media or members of the general public for the purpose of promoting the merits of the SCSEP

To provide information to placement and welfare agencies, prospective employers, school, or training institutions to assist in participant employment

To provide information to Federal, state, and local agencies and community-based organizations to facilitate statistical research, audit, and evaluation activities necessary to insure the success, integrity, and improvement of the SCSEP and other employment and training programs

In addition, any SCSEP participant may submit a request to view his or her records to the grantee or sub-grantee that maintains the records. The grantee or sub-grantee shall respond in a timely manner to all such requests.

Finally, if a person about whom records are maintained submits a written request to a Member of Congress or his or her staff, and that request is forwarded to the U.S. Department of Labor, we may release the information to the Member of Congress or Congressional staff in response to the inquiry made on behalf of the subject of the record.

V. Participant Signature

[Name of SCSEP provider] has given you a copy of this statement, in accordance with the Privacy Act of 1974, as amended, which explains the uses that will be made of information that you or others might supply [name of SCSEP provider] about yourself.

A single copy of this form must be given to each participant for personal reference upon enrollment. Please acknowledge receipt below:

Signature Date

Printed Name