Form ETA 9121 ETA 9121 SPARQ Community Service Form

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Overview

ETA 9121
Services

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Sheet 1: ETA 9121

OMB Control Number 1205-0040 ETA 9121 - Community Service Assignment Expiration Date: 08-31-2018
DATA ELEMENT NAME	DATA TYPE/ FIELD LENGTH	DATA ELEMENT DEFINITIONS/INSTRUCTIONS	CODE VALUE
Assignment	IN	Links the service being entered to a particular Assignment
Host Agency	AN	Record host agency
Type	IN	Select a service Type	Review Services Tab
Grant Number	IN	System-generated
Host Agency Name	AN 225	Record Host Agency Organization Name
Address Line 1	AN 225	Record the Host Agency Organization Address 1
Address Line 2	AN 225	Record the Host Agency Organization Address 2
City	AN 225	Record the Host Agency Organization City
State	AN 2	Record the Host Agency Organization State
Zip	IN 5	Record the Host Agency Organization Zip	00000
FEIN	IN	Record FEIN
Host Agency Type	IN	Record Agency Type	69 Not-for-profit 70 Government
Host Agency Agreement Date	DT 8	Record Agency Agreement Date	YYYYMMDD
Host Agency Monitoring Visit Date	DT 8	Record Agency Monitoring Visit Date	YYYYMMDD
Host agency's site name and location	AN 225	Record the host agency's site name and location
Host agency job codes	AN 225	Record Agency job code 1
Host agency job codes	AN 225	Record Agency job code 2
Host agency job codes	AN 225	Record Agency job code 3
Host Agency Continued Availability	IN 1	Record 1 for active if host agency wishes to continue to participate in the program or if grantee/sub-grantee wishes to continue working with this host agency Record 2 for inactive if host agency no longer wishes to continue to participate in the program or if grantee/sub-grantee no longer wishes to continue working with the host agency	1 = Active 2 = Not Active
Contact First Name	AN 26	Record host agency contact first name
Contact Last Name	AN 26	Record host agency contact last name
Contact Address if different than the host agency address	Checkbox	Record Contact Address if different than host agency address
Survey Contact	IN	Record the participant available survey contact detail
Address Line 1	AN 225	Record the Host Agency Organization Contact Address 1
Address Line 2	AN 225	Record the Host Agency Organization Contact Address 2
City	AN 225	Record the Host Agency Organization Contact City
State	AN 2	Record the Host Agency Organization Contact State
Zip	IN 5	Record the Host Agency Organization Contact Zip	00000
County	AN 225	Record the Host Agency Organization Contact County
Title	AN 225	Record the host agency contact person's title
Phone Number	IN 10	Record the host agency contact person's phone number
Fax Number	IN 10	Record the host agency contact person's fax number
Cell Phone Number	IN 10	Record the host agency contact person's cell phone number
E-mail	AN 26	Record the host agency contact person's email address
Supervisor	AN 26	Record the host agency supervisor's name if different than contact
Host Agency Supervisor's Organization	AN 225	Record the host agency supervisor's organization
Address Line 1	AN 225	Record the Host Agency Host Agency supervisor's Address 1
Address Line 2	AN 225	Record the Host Agency supervisor's Address 2
City	AN 225	Record the Host Agency supervisor's City
State	AN 2	Record the Host Agency supervisor's State
Zip	IN 5	Record the Host Agency supervisor's Zip	00000
County	AN 225	Record the Host Agency supervisor's County
Title	AN 74	Record the host agency supervisor's title
Supervisor's Salutation	AN 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
Funding Source Type	IN	Record 1 if funding source type is federal Record 2 if funding source type is non-federal	1= Federal 2= Non-federal
Supervisor's Hourly Wage	DE 3.2	Record supervisor's hourly wage	0
Supervisor's Number of Hours per week	IN	Record supervisor's number of hours per week
Assignment Date	DT 8	Record assignment date	YYYYMMDD
Assignment Start Date	DT 8	Record assignment start date	YYYYMMDD
Assignment End Date	DT 8	Record assignment end date	YYYYMMDD
Specify Other Reason for Approved Break	AN 225	Specify other reason for approved break
Approved break Comment	AN 2000	Record approved break comment
Participant's Number of Hours per week	IN 3	Record participant's number of hours per week	000
Participant's Schedule	AN 2000	Record participant schedule
Safety Consultation Date	DT 8	Record consultation date	YYYYMMDD
Community Service Assignment Code Type	Radio Button		General Elderly
Community Service Assignment Code	Dropdown	Record community service assignment code	94 G1. Education 95 G2. Health and Hospitals 96 G3. Housing and Home Rehabilitation 97 G4. Employment Assistance 98 G5. Recreation, Parks, and Forests 99 G6. Environmental Quality 100 G7. Public Works & Transportation 101 G8. Social Services 102 G9. Legal 103 G10. Financial 104 G11. Counseling 105 G12. Conservation 106 G13. Community Betterment 107 G14. Other 108E1. SCSEP Project Administration 109 E2. Health and Home Care 110 E3. Housing and Home Rehabilitation 111 E4. Employment Assistance 112 E5. Recreation/Senior Centers 113 E6. Nutrition Programs 114 E7. Transportation 115 E8. Outreach/Referral 116 E9. Legal 117 E10. Financial 118 E11. Counseling 119 E12. Conservation 120 E13. Community Betterment 121 E14. Other
Specify Other Community Service Assignment Code	AN 225	Specify other community service assignment code
Community Service Assignment Title	AN 225	Record community service assignment title
Participant's Job Code	Dropdown	Select Participant Job Code	Review Participant Job Code Tab
Participant's Workers' Compensation Code at Host Agency	AN	Record participant's workers' compensation code
Type	Dropdown	Select type of services	Review Service Tab
Start Date	DT 8	Record supportive service start date	YYYYMMDD
Specify Other Provider of Supportive Services	AN 225	Specify other provider of supportive services
Assignment comment	AN 2000	Record assignment comments
Service Provider Name	AN 225	Record service provider name
Address Line 1	AN 225	Record the service provider contact address 1
Address Line 2	AN 225	Record the service provider contact address 2
City	AN 225	Record the service provider contact City
State	AN 2	Record the service provider contact State
Zip	IN 5	Record the service provider contact Zip	00000
Training provider continued availability	IN 1	Record 1 for active if training provider wishes to continue to participate in the program or if grantee/sub-grantee wishes to continue working with this training provider Record 2 for inactive if training provider no longer wishes to continue to participate in the program or if grantee/sub-grantee no longer wishes to continue working with the training provider	1 = Active 0 = Inactive
Contact First Name	AN 26	Record service provider contact first name
Contact Last Name	AN 26	Record service provider contact last name
Contact person's address	AN 225	Record contact person address if different than host agency address
Address Line 1	AN 225	Record the Host Agency Organization Contact Address 1
Address Line 2	AN 225	Record the Host Agency Organization Contact Address 2
City	AN 225	Record the Host Agency Organization Contact City
State	AN 2	Record the Host Agency Organization Contact State
Zip	IN 5	Record the Host Agency Organization Contact Zip	00000
Salutation	IN 1	Record the host agency contact person's salutation.	1= Mr. 2= Ms. 3= Dr.
Contact	IN 10	Record the host agency contact person's phone number
Ext.	IN 10	Record the host agency contact person's phone extension
Contact	AN 26	Record the host agency contact person's email address
Occupation Code	IN	Enter the 8 digit O*Net 4.0 (or later versions) code that best describes the training occupation for which the participant received training services. Leave blank if occupational code is not available or not known. Additional Notes: If all 8 digits of the occupational skills code are not collected, record as many digits as are available. If the participant receives multiple training services, use the occupational skills training code for the most recent training.	00000000
Participant's Workers compensation code in training	AN 225	Record participant's workers' compensation code
Start Date	DT 8	Record training service start date	YYYYMMDD
Expected End Date	DT 8	Service End Date	YYYYMMDD
Average number of hours of skill training per week	IN 3	Record the average number of hours of skill training per week outside of community service assignment
Average number of hours of community service per week during training	IN 3	Record the average number of hours of community service per week during training
If OJE, wages paid by	IN 1	Record 1 if OJE was paid by the grantee Record 2 if OJE was paid by reimbursing the employer	1= Grantee 2= Employer Reimbursement
If OJE is Reimbursement, percentage of rate	IN 3	Record the percentage of reimbursement rate if OJE is reimbursed
Training Hourly wage	DE 6.2	Record the participant’s training hourly wage Leave blank if the participant was not enrolled in training	000000.00
Total wages paid to participant or reimbursed to employer for OJE	DE 6.2	Record wages paid to participant or reimbursed to employer for OJE	000000.00
Total paid to training provider	DE 6.2	Record total amount paid to training provider for skill training	000000.00
Service Comment	AN 2000	Provide a brief description of service provided to the participant
Ext.	IN 10	Record the host agency contact person's phone ext.
Participant Name	AN 26	Record participant name
Unique Individual Identifier	AN	System-generated
Organization	AN 225	Record organization Name
Program Year	IN 4		XXXX
Status	Dropdown	System-selection (pending; pending eligibility approval; eligible; active; exited-in follow-up; exited-closed)
Enrollment From	DT 8	System-selection	YYYYMMDD
Enrollment To	DT 8	System-selection	YYYYMMDD
Exit From	DT 8	System-selection	YYYYMMDD
Exit To	DT 8	System-selection	YYYYMMDD
Service Provider	IN	Search available service provider in system
Training Completed?	IN 1	Record 1 if the participant completed approved training Record 0 if the participant did not complete training (withdrew). Leave blank if the participant did not receive a first training service or this data element does not apply to the participant	1 = Yes 0 = No
Cost of Service	DE 6.2	Record the participant cost of service	000000.00
Ext.	AN 10	Record phone extension
Is Documentation Provided	IN 1	Record 1 if documentation for approved break is provided Record 0 if documentation for approved break is not provided	1 = Yes 0 = No
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.

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Sheet 2: Services

Category	Type
Career Services	Assessment of Skill Level and Other Service Needs
Career Services	Orientation
Career Services	Work-related Safety Training
Career Services	Job Clubs
Career Services	Job Fairs
Career Services	Job Placement and Job Search Assistance
Career Services	Career Counseling
Career Services	Health, Wellness, and Nutrition (e.g. RX, Medical needs, and Meals on Wheels)
Career Services	Counseling (e.g. Grandparents raising Grandchildren)
Career Services	Benefit Check-up Counseling
Career Services	Civic Engagement
Career Services	Computer Based Training via online modules (Non-Industry recognized certificate(s))
Career Services	Individual Employment Plan (IEP)
Career Services	Individual Counseling (e.g. Legal Service and Substance Abuse)
Career Services	Career Planning (e.g. Resume and interviewing assistance)
Career Services	Financial Literacy Services
Career Services	Tutoring, Study Skills Training, Dropout Prevention
Career Services	Other Counseling (Specify)
Career Services	Test of English as a Foreign Language (TOEFL)
Career Services	Test for Adult Basic Education (TABE) /Comprehensive Adult Student Assessment Systems (CASAS)
Community Service Assignment	Soft Skills (e.g. Hygiene, Communications skills, and Social interactions)
Community Service Assignment	Short-term Prevocational Services
Community Service Assignment	Programs that combine workplace training with related instruction
Community Service Assignment	Skills upgrading and retraining
Community Service Assignment	Job Readiness Training
Training	Occupational Skills Training
Training	On-the-Job-Experience (OJE)
Training	Apprenticeship Training
Training	Entrepreneurship Training
Training	Digital Literacy Training
Training	Educational Remediation and Literacy Training (i.e. Adult Basic Education, Alternative Secondary School, GED or other High School Equivalent Credential)
Training	Limited English Proficiency (ESL)
Referral	One-Stop (Known as American Job Center)
Referral	Job Clubs/Fairs
Referral	Job Placement and Job Search Assistance
Referral	Job Interviews
Referral	Social Services or Other Public Assistance
Referral	Another SCSEP project
Referral	Department of Veterans Affairs (i.e. Vocational Rehabilitation and Employment Program, and other VA Services)
Referral	Federal Training
Referral	Health and Human Services Programs
Referral	Other Federal/State Assistance Services (specify)
Referral	Others (Substance Abuse, Mental Health, Legal Services, etc.) (Specify)
Supportive Service	Transportation Assistance
Supportive Service	Work Attire (i.e. Uniforms and badges)
Supportive Service	Work Related Tools
Supportive Service	Employment (Job or Training) Related Fees
Supportive Service	Eye Glasses, etc.
Supportive Service	Meal Assistance
Supportive Service	Housing (i.e. Temporary Housing Assistance)
Supportive Service	Dependent care (i.e. Child or Adult Care Assistance)
Supportive Service	Health and medical services (i.e. RX and Annual Physical)
Supportive Service	Needs-related payment, such as utilities or food
Supportive Service	Special job-related or personal counseling (received at follow-up)
Supportive Service	Educational Testing Fees
Supportive Service	Occupational Licensing Fees
Supportive Service	Educational Assistance with Books, School Supplies, Other Fees
Supportive Service	Others (Specify)
Follow-Up Services	Help Participant Get Another Job
Follow-Up Services	Intervention with Employer
Follow-Up Services	Counsel Participant on Job-Related Issues
Follow-Up Services	Request for Supplemental Information
Follow-Up Services	Supportive Services