Service Termination Information

APPENDIX B-3

Participant Service Termination Form

(as part of Program Participation Forms)

Participant Service Termination Form

To be filled by MDO staff:

Applicant’s Name: _____________________________________________________________

First Name MI Last Name

SET Participant Number: ________________________________________________________

Assigned SET Provider: _________________________________________________________

Date of Assignment to the SET Program: ____________________________________________

Designated SET Advisor: ________________________________________________________

Date of Program Termination: ______________ Referred Back to AJC (Y/N):____________

Reason for termination: _________________________________________________________

To be filled by MDO staff:

Reason for termination of program support and services to SET participant: ________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

To be filled by participant:

Participant comments (Optional):___________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Participant Signature: I have read the explanation provided above by the MDO staff member and agree with the decision to terminate program services.

_____________________________ _________________________ ___________

Print Name Signature Date

To be filled by MDO staff ONLY if participant signature is not obtained:

Explanation of why participant signature could not be obtained: (Required):________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

OMB Control No.: xxxx-xxxx, Expiration Date: xx/xx/20xx

Public Burden Statement

The SET Demonstration is being carried out under the legal authority of PL 105-220 (subtitle D [sections 171 and 172]). Completing this document, which seeks to help the U.S. Department of Labor understand the effects of SET services on customers’ employment-related outcomes, is required to obtain or receive the benefit of a reimbursement for service delivery. The public reporting burden for this collection of information is estimated to average 20 minutes 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 Office of Policy Development and Research, U.S. Department of Labor, Room N5641, 200 Constitution Avenue, NW, Washington, DC 20210.