6200-04 Job Training Reporting Form

United States ENVIRONMENTAL PROTECTION AGENCY Washington, DC 20460

JOB TRAINING REPORTING FORM

Public reporting burden for this collection of information is estimated to average x 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 I - COOPERATIVE AGREEMEMENT RECIPIENT INFORMATION

1. Cooperative Agreement Recipient Name:

2. Cooperative Agreement Number:

PART II - PERFORMANCE MEASURES INFORMATION

This Federal Fiscal QUARTER

CUMULATIVE

3. Number of Participants Entering Training

3a. Number of Veterans Entering Training

4. Number of Participants Completing Training

5a. Number of Participants Obtaining Employment

5b. Number of Individuals that did not Obtain Employment but are Pursuing Education (e.g., GED, college courses, etc.)

6. Average Hourly Wage of Participants Obtaining Employment

7. Funds Leveraged (total)

7-1. Funding Source Name:

7-2. Activity Funded:

7-1. Funding Source Name:

7-2. Activity Funded:

7-1. Funding Source Name:

7-2. Activity Funded:

8. Supplemental Performance Measures Information (optional):

PART III - APPROVALS

9. Cooperative Agreement Recipient Project Manager:

Name (please print)

Signature:

Date:

10. U.S. EPA Regional Representative:

Name (please print)

Signature:

Date: