Form ETA 655 ETA 655 Statement from Court or Other Agency

OMB Control No. 1205-0025

Expiration Date: 11/30/2013

U.S. Department Labor

Employment and Training Administration

Statement from Court or Other Agency

Section I

Applicant Information:
1. Student ID:	2. Name:			3. Date of Birth:			4. Sex:
5. Address:
Counselor Office Information:
6. Name:		7. Address:
Court or Other Agency Information:
8. Name:		9. Address:
10. Contact Name:			11. Contact Title:		12. Phone:
Information of Person or Agency to whom the applicant was released:
13. Name:		14. Address:				15. Phone:

Section II

The following information is to be completed by the Court, Supervising Agency, or Authorized Person:
16. Date the applicant first entered the jurisdiction:	17. Date the applicant was/will be released from your jurisdiction:
18. List all of the complaints which were sustained:
19. Describe applicant’s adjustment while under supervision of the court or other agency:
20. Describe any aspects of the applicant’s background, personality, or behavior which Job Corps should know about:
21. Describe any difficulties the applicant might have in adjusting to a Job Corps Center:

Can this applicant be expected to:
Live and work well with other students?	Recognize and respond to discipline?			Benefit from Job Corps?
Behave properly in communities near the center?			Not prevent others from benefiting from Job Corps?
Be free of all court-imposed obligations?	Be released/suspended from all financial obligations until Job Corps separation?
Is there a court appearance pending? (If so, Explain)
If applicant is currently under agency jurisdiction or supervision, will agency:
Release applicant upon departure to Job Corps?		Permit applicant to leave the state while enrolled?
Agree not to exercise personal or face-to-face supervision during enrollment?
Authorize Job Corps to send applicant to another state upon completion of the program?
Does agency wish a report from Job Corps if arrested during enrollment:
Prior to court disposition?		Subsequent to court disposition?

Signature of Point of Contact Date

Privacy Act Notice:

All request for personal information about students must be treated as requests under the Freedom of Information Act and the Privacy Act of 1974, and handled pursuant 29 CFR Parts 70 and 70a and 45 CFR Parts 160 and 164.

Public Burden Statement:

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 111-5). Public reporting burden is estimated to average 1 minute per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371). Please do not submit completed forms to this address.

STATEMENT FROM COURT OR OTHER AGENCY

1. Purpose. This form is used to obtain documentation of the applicant’s behavior from the officer of the appropriate juvenile or adult court or court-designated agency. It applies to an applicant who has had an arrest or complaint record or has been under supervision as a result of court action since age 14. Information is important in determining whether an applicant can adjust to Job Corps.

2. Originator. Job Corps Admission Counselor.

3. Frequency. For applicants with records of behavioral problems.

4. Distribution. All copies to the ETA Regional Office except if the applicant is determined to be ineligible at the admissions level. See (No. 8) for disposition.

5. General Instructions. If the applicant has an arrest or complaint record or has been under supervision as a result of court action since age 14, send the Statement From Court or Other Agency, Form ETA 6-55, to the officer of the appropriate juvenile or adult court or court-designated agency for completion. If the applicant was arrested in any other city since age 14, the appropriate court must also be asked to complete Form ETA 6-55. The information entered on this form will be used only by authorized personnel and will be kept strictly confidential.

6. Detailed Instructions.

Section I To Be Completed by Job Corps Admissions Agency

Admissions Counselor completes Section I of the form, when applicable, prior to submission to the appropriate juvenile or adult court or court-designated agency.

Item

1. Student Identification No.

2-5. Self-explanatory.

6-8. Self-explanatory.

Section II To be completed by the court, supervising agency, or authorized person

9-10. Self-explanatory.

11-13. Self-explanatory.

14-15. Self-explanatory.

16. Self-explanatory.

17-21. Self-explanatory.

7. Special Instructions. A fact sheet concerning Job Corps is printed on the back of the form. The admissions counselor is requested to make the following changes on the fact sheet before submission to the appropriate court agency:

1. Under “Youth with Court Imposed Financial Obligations”, Line 3, reference to support payment should be changed to read “for spouse or dependent child(ren).”

b. Delete the note at the bottom of the fact sheet which makes reference to Residential Manpower or Residential Support Center.

8. Disposition. If the applicant is determined to be ineligible for behavior reasons at the admissions level, the Admissions Counselor destroys all copies of the form immediately. If the applicant is determined to be ineligible at the regional level, the ETA Regional Office should retain all the behavior information in a confidential manner for one year for the purpose of cross reference against reapplication.

9. Further Explanation. If the applicant is on probation or parole, the Admissions Counselor will notify the appropriate probation or parole officer when the applicant’s application is approved or denied. If approved, the Admissions Counselor will provide the name and address of the center to which the applicant is assigned and the scheduled date of departure. The Admissions Counselor will also notify the appropriate officer if the applicant’s departure date has changed, if the applicant refused the assignment, or if the applicant does not show up for departure.

ETA Form 655