Form ETA 9123 ETA 9123 SPARQ Exit Form

OMB Control Number 1205-0040 ETA 9123 - Exit Expiration Date: 08-31-2018

DATA ELEMENT NAME

DATA TYPE/ FIELD LENGTH

DATA ELEMENT DEFINITIONS/INSTRUCTIONS

CODE VALUE

Self Employed

AN

Record 1 if participant is self-employed Record 0 if participant is not self-employed

1=Yes 0= No

Termination Letter Date

DT 8

Record the termination letter date

YYYYMMDD

Signature of participant (Waiver Certification)

AN 74

Record the signature of the participant on recertification

Date of signing (participant)

DT 8

Record the date on which the participant signed the exit form

YYYYMMDD

Exit Comment

AN 2000

Record exit comment

Recipient Grantee

AN

Record recipient grantee name

Recipient Sub-grantee

AN

Record recipient sub-grantee name

Transfer Effective Date

DT 8

Record the effective date of transfer

YYYYMMDD

Reason For Transfer

AN

Record the reason for getting transfer

164 Result of approved swap of authorized positions 165 Participant was orphaned 166 Other administrative reason 167 Participant is moving 168 Other

Recipient Grant

IN

Record the receipt Org Grant Number where participant case is getting transferred

Reviewer Decision

AN 2000

Record 1 if reviewer approved the transfer Record 0 if reviewer did not approve the transfer

1=Yes 0= No

Comments to Requester

AN 2000

Record any additional comment

Donor Concurrence

IN 1

Record 1 if donor concur with the transfer Record 0 if donor did not concur with the transfer

1=Yes 0= No

Right of first refusal?

IN 1

If the transfer request is initiated by the grantee for administrative reasons, the request must state that the transferred participant will receive: timely notice and explanation, the right of first refusal for 90 days, and the application of the more liberal of the two grantees’ IDL policy for 90 days. Record 1 if the transfer request is initiated by the grantee for administrative reasons Record 0 if the transfer request is not initiated by the grantee for administrative reasons

1=Yes 0= No

Program Office Concurrence

IN 1

If the transfer request is initiated by the grantee for administrative reasons, the National Office must concur. Record 1 if program office concurred Record 0 if program office did not concurred

1=Yes 0= No

Is the transfer due to a swap of positions between grantees?

IN 1

Record 1 if transfer is due to a swap of positions between grantees Record 0 if transfer is not due to a swap of position between grantees

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 3 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.