Form ETA 9122 ETA 9122 SCSEP Unsubsidized Employment Form

OMB Control Number 1205-0040 ETA 9122 - Unsubsidized Employment Expiration Date: 08-31-2018

DATA ELEMENT NAME

DATA TYPE/ FIELD LENGTH

DATA ELEMENT DEFINITIONS/INSTRUCTIONS

CODE VALUE

Survey Contact

IN

Record the contact person’s name as it should appear on the cover letter and mailing envelope for the customer satisfaction survey

Employer

AN 225

Record the participant employer details

Successful Follow-Up with Employer/Participant Quarter 1 after exit?

IN 1

Record 1 if follow-up was successful with employer/participant to obtain supplemental employment information for quarter 1after exit Record 0 if follow-up was successful with employer/participant to obtain supplemental employment information for quarter 1after exit

1 = Yes 0 = No

Successful Follow-Up with Employer/Participant Quarter 2 after exit?

IN 1

Record 1 if follow-up was successful with employer/participant to obtain supplemental employment information for quarter 2 after exit Record 0 if follow-up was successful with employer/participant to obtain supplemental employment information for quarter 2 after exit

1 = Yes 0 = No

Successful Follow-Up with Employer/Participant Quarter 3 after exit?

IN 1

Record 1 if follow-up was successful with employer/participant to obtain supplemental employment information for quarter 3 after exit Record 0 if follow-up was successful with employer/participant to obtain supplemental employment information for quarter 3 after exit

1 = Yes 0 = No

Successful Follow-Up with Employer/Participant Quarter 4 after exit?

IN 1

Record 1 if follow-up was successful with employer/participant to obtain supplemental employment information for quarter 4 after exit Record 0 if follow-up was successful with employer/participant to obtain supplemental employment information for quarter 4 after exit

1 = Yes 0 = No

Follow-up 4th Quarter scheduled date

DT 8

This date is the first day of the 4th quarter after the exit quarter Note: System-generated

YYYYMMDD

Date of Follow-Up

DT 8

Record the date on which the 4th Quarter follow-up is conducted

YYYYMMDD

Mode of Contact

Dropdown

Record the participant mode of contact during 4th Quarter follow-up

60 In Person 61 Phone 62 Email or Written Report 63 Other

Ext.

IN 10

Record employer phone ext.

Name

AN 225

Record employer name

Address Line 1

AN 225

Record employer address 1

Address Line 2

AN 225

Record the employer address 2

City

AN 225

Record the employer city

State

AN 2

Record the employer State

Zip

IN 5

Record the Host Agency Organization Contact Zip

00000

FEIN

AN

Record employer FEIN

Did employer provide an OJE training site

IN 1

Record 1 if employer provided an OJE training Record 0 if employer did not provide OJE

1 = Yes 0 = No

Site Name and Location

AN 225

Record employment site name and location if different from main address

Date for next customer satisfaction survey for this employer

DT 8

Record the date for next customer satisfaction survey for this employer Note: System-generated

YYYYMMDD

Employer Continued Availability

IN 1

Record 1 for active if employer wishes to continue to participate in the program or if grantee/sub-grantee wishes to continue working with this employer Record 2 for inactive if employer no longer wishes to continue to participate in the program or if grantee/sub-grantee no longer wishes to continue working with the employer

1 = Active 0 = Inactive

Contact First Name

AN 26

Record the employer contact person's first name

Contact Last Name

AN 26

Record the employer contact person's start name

Contact Person's Address

checkbox

Select if the Employer Contact Person address is different than the employer address

Address Line 1

AN 225

Record the Employer Contact Person Address 1 if different than employer address

Address Line 2

AN 225

Record the Employer Contact Person Address 2 if different than employer address

City

AN 225

Record the Employer Contact Person City if different than employer address

State

AN 2

Record the Employer Contact Person State if different than employer address

Zip

IN 5

Record the Employer Contact Person Zip if different than employer address

00000

Zip+4

IN 4

XXXX

County

AN 26

Record employer county

Title

AN 74

Record the Employer Contact person's title

Salutation

IN 1

Record the Employer Contact person's salutation

1= Mr. 2= Ms. 3= Dr.

Phone Number

IN 10

Record the Employer Contact person's phone number

Fax Number

IN 10

Record the Employer Contact person's fax number

Cell Phone Number

IN 10

Record the Employer Contact person's cell phone number

E-mail

AN 26

Record the Employer contact person's email address

Supervisor

AN 26

Record supervisor's name for participant's employment

Supervisor's mailing address if different

AN 225

Record supervisor mailing address for employer if different from employer contact

Address Line 1

AN 225

Record the address 1 for supervisor

Address Line 2

AN 225

Record the employer Address 2 for supervisor

City

AN 225

Record the employer City for supervisor

State

AN 2

Record the employer State for supervisor

Zip

IN 5

Record the Host Agency supervisor's Zip

00000

Title

AN 74

Record the host agency supervisor's title

Salutation

IN 1

Record the host agency Supervisor's salutation

1= Mr. 2= Ms. 3= Dr.

Phone number

IN 10

Record the host agency Supervisor's phone number

Fax number

IN 10

Record the host agency Supervisor's fax number

Cell phone number

IN 10

Record the host agency Supervisor's cell phone number

E-mail

AN 26

Record the host agency supervisor's email address

Job Title

AN 74

Record the participant job title

Occupational Code

IN

O-Net Occupation Code

Entered Training-Related Employment

IN 1

Record 1 if after training program completion, the employment in which the individual entered uses a substantial portion of the skills taught in the training received by the individual. This data element is training program completion based. Individuals that have not enrolled in and completed training should not be reported in this data element. Record 0 if the employment in which the individual entered does not use a substantial portion of the skills taught in the training received by the individual. Record 9 if unknown. Leave blank if the individual has not completed a training program and/or has not yet entered employment

1 = Yes 0 = No

Type

Dropdown

Select type of services

See Services Tab

Specify Other Provider of Supportive Services

AN 225

Specify other provider of supportive services

Start Date

DT 8

Service Start Date

YYYYMMDD

Unsubsidized Employment Comment

AN 2000

Record the participant unsubsidized employment comments

Customer Service Survey 1 number

IN

Record survey #1 number

Customer Service Survey 1 date

DT 8

Record the date for the first survey delivered to a qualified employer

YYYYMMDD

Customer Service Survey 2 number

IN

Record survey #2 number

Customer Service Survey 2 date

DT 8

Record the date for the second survey delivered to a qualified employer

YYYYMMDD

Customer Service Survey 3 number

IN

Record survey #3 number

Customer Service Survey 3 date

DT 8

Record the date for the third survey delivered to a qualified employer

YYYYMMDD

90-day date

DT 8

In order for the participant to exit for purposes of the Core Measures, the participant must not have received any program services (other than the specifically defined follow-up activities or services) for 90 days. Record the 90-day date for when to check to see if the participant has received additional services.

YYYYMMDD

Follow-up 1st Quarter scheduled date

DT 8

This date is the first day of the 1st quarter after the exit quarter Note: System-generated

YYYYMMDD

Date of Follow-Up

DT 8

Record the date of 1st Quarter follow-up

YYYYMMDD

Mode of Contact

Dropdown

Record the participant mode of contact during 1st Quarter follow-up

60 In Person 61 Phone 62 Email or Written Report 63 Other

Follow-up 2nd Quarter scheduled date

DT 8

This date is the first day of the 2nd quarter after the exit quarter Note: System-generated

YYYYMMDD

Date of Follow-Up

DT 8

Record the date of 2nd Quarter follow-up

YYYYMMDD

Mode of Contact

Dropdown

Record the participant mode of contact during 2nd Quarter follow-up

60 In Person 61 Phone 62 Email or Written Report 63 Other

Total Quarterly Earnings

DE 6.2

Record the participant total quarterly earning during 2nd Quarter

000000.00

Follow-up 3rd Quarter scheduled date

DT 8

This date is the first day of the 3rd quarter after the exit quarter Note: System-generated

YYYYMMDD

Date of Follow-Up

DT 8

Record the date on which the 3rd Quarter follow-up is conducted

YYYYMMDD

Mode of Contact

Dropdown

Record the participant mode of contact during 3rd Quarter follow-up

60 In Person 61 Phone 62 Email or Written Report 63 Other

Customer satisfaction and follow-up comment

AN 2000

Record customer satisfaction and follow-up comment

Public Burden Statement (1205-0040)

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondent’s reply to these reporting requirements is mandatory (Older Americans Act Reauthorization Act of 2016 and Workforce Innovation and Opportunity Act, Section 116). Public reporting burden for this collection of information is estimated to average 6 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 Workforce Investment ● U.S. Department of Labor ● Room C-4510 ● 200 Constitution Ave., NW, ● Washington, DC ● 20210. Do NOT send the completed application to this address.