Form ETA-9140-A Beneficiary Choice Quarterly Performance Report

STANDARDIZED QUARTERLY PERFORMANCE REPORT

Beneficiary-Choice Contracting Grant

Report Due Date: mm/dd/yyyy

OMB No.

1205-0455

ETA Form No. ETA-9140-A

Expires:

1/31/2009

A. GRANTEE IDENTIFYING INFORMATION

Grantee Name:

Grant Number:

Program/Project Name:

Project or Sub-Project ID/Number:

Report Quarter End Date:

City ________________________________

State ______

Zip Code __________

Enrollment Goal:

Performance Items

Previous Quarter (A)

Current Quarter (B)

Cumulative for Program Year (C)

Program-to-Date (D)

B. PARTICIPANT SUMMARY INFORMATION

1. Total Exiters

2. Total Participants Served

3. New Participants Served

Gender

4a. Male

4b Female

Ethnicity / Race

5a. Hispanic/Latino

5b. American Indian or Alaska Native

5c. Asian

5d Black or African American

5e. Hawaiian Native or Other Pacific Islander

5f. 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

Age

7a. 18 - 29

7b. 25 - 34

7c. 35 - 44

7d. 45 - 54

7e. 55 or older

Other Demographics

8. Eligible Veterans

9. Limited English Proficient

10. Persons with a Disability

11. Not Employed at Program Participation

C. Additional Participant Information to be collected at enrollment

Housing Status

1a. Own/rent apartment, room, or house

1b. Staying at someone's apartment, room or house (Stable)

1c.. Halfway house/transitional house

1d. Residential treatment

1e. Homeless

1f. Staying at someone's apartment, room or house (Unstable)

2. History of Alcohol Abuse/Drug Use

3. Average Number of Days Since Release

4. Average Number of Years Incarcerated

Post-Release Status

5a. Parole

5b. Probation

5c. Other Post-Release Supervision

5d. None

Type of Crime

6a. Property Crimes

6b. Drug Crimes

6c. Public Order Offenses

6d. Other Offenses

7. DOJ Pre-Release Participants

Performance Items

Previous Quarter (A)

Current Quarter (B)

Cumulative for Program Year (C)

Program-to-Date (D)

Value

Numerator

Value

Numerator

Value

Numerator

Value

Numerator

Denominator

Denominator

Denominator

Denominator

D. PROGRAM SERVICES, ACTIVITIES, AND OTHER RELATED ASSISTANCE

1. Received Education or Job Training Activities

2. Received Workforce Preparation Activities

3. Community Involvement Activities

4. Received Mentoring Activities

5. Received Health Services

6. Received Supportive Services

7. Overall Participation Rate (participating in at least one activity from 1 through 5. Does not include supportive services.)

Performance Items

Previous Quarter (A)

Current Quarter (B)

Cumulative for Program Year (C)

Program-to-Date (D)

Value

Numerator

Value

Numerator

Value

Numerator

Value

Numerator

Denominator

Denominator

Denominator

Denominator

E. SHORT-TERM INDICATORS OF PERFORMANCE

Leading Indicators of Performance

1. Enrollment Rate

2. Abstained from Alcohol Abuse or Illegal Drug Use (6 months after enrollment)

3. Stable Living Arrangements (6 months after enrollment)

4a. Number of Initial Job Placements

4b. Average Hourly Wage Rate at Placement

4c. Number of Job Re-Placements

4d. Average Hours Worked 1st Week of Placement

5. Number Obtained High School Diploma or GED

6. Number Obtained a Certificate

7. Entered Post Secondary Education

8. Entered Vocational/Occupational Skills Training

9a. Number of Re-arrests for a New Crime -- one year

9b. Number of Re-arrests for a New Crime -- six months

9c. Number of Re-Incarcarations for New Crime 6 Mos.

9d. Number of Re-Incarcarations for New Crime 1 yr.

9e. Number of re-Convictions for New Crime 6 mos.

9f. Number of re-Convictions for New Crime 6 mos.

F. LONG-TERM INDICATORS OF PERFORMANCE

Common Performance Measures

1. Entered Employment Rate

2. Employment Retention (includes all participants who entered employment, regardless of follow-up)

3. Attainment of a Degree Or Certificate

4. Average 6 Months Post-Program Earnings (includes only those who have been successfully contacted during follow-up)

Additional Performance Measures

5. Recidivism Rate

G. REPORT CERTIFICATION/ADDITIONAL COMMENTS

Grantee Remarks:

Name of Grantee Certifying Official:

Telephone Number:

Email: