Project Synopsis Form 9106 (track changes)

U.S. Department of Labor OMB Control No. 1205-0439

Employment and Training Administration Expiration Date: 79/301/20163

Project Synopsis Form ETA 9106

National Emergency Grant National Dislocated Worker Grants Electronic Application System

State of _______	Amount of Funding Request $____________		Amount Approved by DOL $_____________
Project Name:
Project Type: ___RegularEmployment Recovery ___Disaster Recovery ___Trade Dual Enrollment ___Trade Health Insurance Coverage (HCTC)
Application Type: ___Full ___Emergency (If Emergency – reason : __________________________________________________________________________________)
For RegularEmployment Recovery Project Application ONLY: Description/Type of Eligible Dislocation Event : ___Plant Closure/Mass Layoff ___Community Impact Layoffs ___Military Installation ___Industry Wide ___Higher Than Average Demand for Services from Dislocated Service Members Description of Activities to be Provided:
For Disaster Recovery Project Application ONLY: Name/Description of Disaster Event/Activities to be Provided:________________________________________________________________________ Date of FEMA Declaration of Eligibility for Public Assistance: __________; or Date of Eemergency or dDisaster sSituation of nNational sSignificance: ________ Name of Federal Agency Ddeclaring dDisaster eEvent (if other than FEMA): __________ Target Groups (check all that apply): ___Unemployed Due to Disaster ___Long-Term Unemployed ___Dislocated Workers ____Evacuees Ffrom a dDeclared dDisaster Aarea
For Trade Health Insurance Coverage Project Application ONLY: State-based Qualified Health Insurance Coverage Programs Selected by State: ___Continuation Provision High-Risk Pool ___ State Employees ___Sate Employee-Comparable ___Joint State-Private Non-Pool ___Joint State-Private Pool ___Non-federally Financed
Applicant Contact Person:
Street Address 1:
Street Address 2:
City: ____________________________ State: _________________________ Zip Code
Telephone:
FAX:
Email:
Planned Number of Participants: __________		Planned Entered Employment Rate: __________%
Planned Cost Per Participant: $___________		Actual Cost Per Participant in Prior PY: $ __________
% of Planned Participants Receiving NRPs: _______		Planned Earnings: ___________%
Counties Included in Project Service Area:
Project Operator Listing:

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 ( PL: 107-210). Public reporting burden for this collection of information is estimated to average 60 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. This is public information and there is no expectation of confidentiality. Send comments regarding this burden estimate to the U.S. Department of Labor, Office of National Response, Room C-5311, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371).

ETA Form 9106(March 2004)