Form 6200-04 JOB TRAINING REPORTING FORM

United States

ENVIRONMENTAL PROTECTION AGENCY

Form Approved
OMB No. 2050-0192
Expires 07-31-2009

Washington, DC 20460
JOB TRAINING REPORTING FORM
Brownfields
PART I – GRANT RECIPIENT INFORMATION
1. Grant Recipient Name

2. Grant Number

Public reporting burden for this collection of information is
estimated to average 5 hours per response, including the
time for reviewing instructions, searching data sources,
gathering and maintaining the data needed, and completing
and reviewing the collection of information. Send comments
regarding this burden estimate, or any other aspect of this
collection of information, including suggestions for reducing
this burden, to the Environmental Protection Agency, Office
of Environmental Information, Code 2822T, Washington, DC
20460 and to the Paperwork Reduction Project, Office of
Management and Budget, Washington, DC 20503. DO NOT
RETURN your form to either of these addresses. Send your
completed form to the address provided by the issuing
office.

PART II – PERFORMANCE MEASURES INFORMATION
Table A – Mandatory Performance Measures
Measure
3. Number of Participants Completing Training

(a) This Quarter

(b) Cumulative

4. Number of Participants Obtaining Employment
5. Average Hourly Wage of Participants Obtaining Employment
6. Funds Leveraged (total)
6-1. Funding Source Name
6-2. Activity Funded
6-1. Funding Source Name
6-2. Activity Funded
6-1. Funding Source Name
6-2. Activity Funded
7. Supplemental Performance Measures Information (optional)

PART III – APPROVALS
8. Grant Recipient Project Manager
Name
Signature

Date

9. US EPA Regional Representative
Name
Signature

Date

EPA Form 6200-04 (9-2006)

INSTRUCTIONS FOR COMPLETING
JOB TRAINING REPORTING FORM - BROWNFIELDS
GENERAL INSTRUCTIONS
Overview:
As specified in your grant terms and conditions, all job training grant recipients must report to EPA on a
regular basis. This OMB and EPA approved reporting form (OMB No. 2050 - 0192, EPA Form 6200-04),
supplements your Quarterly Reports with information about specific activities and accomplishments that
EPA deems necessary to adequately monitor and evaluate the performance of job training grants. Please
contact your EPA Regional representative if you have any questions when completing this form. Please note
that, in most instances, all reported information is accessible by the public under the Freedom of
Information Act (FOIA) and may be distributed by EPA to the public unless one of the FOIA exclusions is
applicable.
Compared to the Quarterly Reports, the Brownfields Job Training Reporting Form (JT Reporting form)
contains quantitative information relating to four specific measures of grant recipient performance.
Reporting on these specific activities and accomplishments must be provided in the attached JT Reporting
form rather than in the Quarterly Reports. Additional voluntary and/or narrative information may be
provided in Part II of this form or in the Quarterly Report.
When to Submit:
Original JT Reporting Forms. Grant recipients must develop the first JT Reporting form when the first
specified accomplishment has occurred (e.g., when the first class of trainees “graduates” from the training
program provided under the grant, or when leveraged funding is committed to supplement the grant
activities). The form should be attached and delivered with the next required Quarterly Report.
Updated JT Reporting Forms. JT Reporting forms should be updated and delivered as additional
accomplishments occur, and should be attached to the next required Quarterly Report. In addition, an
updated form should be provided when the grant is being closed-out.
To Whom to Submit:
Grant recipients must submit JT Reporting Forms to their EPA Regional Representative identified in the
terms and conditions of the cooperative agreement. The EPA Regional Representative may request the form
also be submitted to the EPA Headquarters Data Manager. When online submission is available and JT
Reporting Form information is entered online the data will automatically be delivered to the EPA Regional
Representative.
How to Submit:
EPA is undertaking a two-phased process to facilitate electronic reporting and provide an information
dissemination system to facilitate future grant recipient reporting. EPA will prepare electronic versions of
this and other required reporting forms for the grant recipients to complete and submit via e-mail. When the
Assessment, Cleanup, and Redevelopment Exchange System, (ACRES) is available on online to grant
recipients, JT Reporting Form information may be entered electronically into the web-based database.
Electronic reporting is optional; hard copy reports will always be acceptable.

EPA Form 6200-04 (9-2006)

DETAILED INSTRUCTIONS FOR COMPLETING EACH ITEM ON FORM
PART I - GRANT RECIPIENT INFORMATION
1. Grant Recipient Name. Enter the grant name. Use the official name of the grant recipient as provided
in the cooperative agreement, unless otherwise directed by the EPA Regional Representative.
2. Grant Number. Enter the grant number. Use the number of the grant as provided in the cooperative
agreement.
PART II - PERFORMANCE MEASURES INFORMATION
This section contains two parts—one mandatory, for certain limited performance measures information
(Table A); the other optional, for narrative information to supplement the quantitative information provided
(section 7).
Table A - Mandatory Performance Measures. In Table A, provide all quantitative information relating to
each of the four (4) mandatory performance measures. For each measure, enter amounts in column (a) –
This Quarter – to reflect the incremental accomplishments attained during the current reporting quarter and
column (b) – Cumulative – to reflect the total accomplishments attained to date during the term of the grant.
Note: Quantitative information relating to these performance measures should only be provided in the table
(i.e., not in narrative reporting contained in the Quarterly Report).
3. Number of Participants Completing Training. Enter the number of participants taking the grant
funded training who have completed the training program.
4. Number of Participants Obtaining Employment. Enter the number of graduates from the grant funded
training program who have obtained employment of any kind. Self-employed graduates should be included
in this count. The cumulative total number inserted in column (b) should only increase during the term of the
grant; the grant recipients’ quantitative reporting of the cumulative total should not reflect any decreases for
graduates who had obtained employment, but later report losing their jobs. If desired, provide a brief
narrative description in section 7 for any reported job losses.
5. Average Hourly Wage. Enter the average hourly wage of job training graduates in their initial posttraining employment. Provide the hourly wage for the first job that each employed graduate secures after
completing the job training program. Anecdotal information about subsequent jobs and wages may also be
narratively provided by the grant recipient.
6. Funds Leveraged. Enter the total amount of funding leveraged as a result of grant activities. Capture the
total number of non-grant dollars linked and leveraged to support additional, related activities of the grant
recipient. To be reportable, there must be a demonstrable link or connection between the EPA funded
activity and the leveraged funding. Funding can occur through direct financial assistance and/or through inkind services or supplies. Usually, leveraged funding that was committed prior to the award of the EPA
grant should not be reported as leveraged since the activity predates the award. In addition, leveraged
funding should not be reported in this section until the funding has been committed. These leveraged funds
may be used to support activities that cannot be funded by the EPA grant (e.g., transportation or child care
for job training students).
EPA Form 6200-04 (9-2006)

In addition to the total leveraged funds, also describe the source and amount of funding leveraged, and the
types of activities it funded. For each funding source (6-1), also list the type of activity funded (6-2) and the
amount of funding leveraged per source in columns (a) and (b). As necessary, add additional lines for 6-1
and 6-2.
6-1. Funding Source Name(s). For each funding source, enter the name of the organization
providing the funds and/or in-kind services. Examples of sources of leveraged funding include other
EPA programs, private organizations, state environmental, labor, or economic agencies, tribal
governments, local governments (including community development corporations), and other federal
agencies.
6-2. Activity Funded. For each funding source listed under 6-1, provide the type of activity that
was supported. Examples of leveraged activities include additional curricula development/training
(e.g., environmental and non-environmental), supplies/equipment, transportation for students, and
child care for students.
7. Supplement Performance Measures Information (Optional). Provide a brief narrative description to
supplement the required performance measures reporting, including, for example: demographic information
(e.g., gender, age, ethnicity, education); description of the training curricula; information on the types of jobs
obtained by the participants entering/completing the training; availability of photographs/video footage of
the training/graduation/post-training employment; and/or specific milestones tracked by the grant recipient
for its own management.
PART III - APPROVALS
8. Grant Recipient Project Manager. Type or print the name of the grant recipient project manager. The
project manager should also sign and date the completed JT Reporting form before submission.
9. U.S. EPA Regional Representative. Type or print the name of the EPA Regional Representative. The
EPA representative should also sign and date the reviewed JT Reporting form.

EPA Form 6200-04 (9-2006)