Form ETA 9121 ETA 9121 SPARQ Community Service Assignment Form

SCSEP Community Service
Assignment Form

OMB Approval Number: 1205-0040
Expiration Date: 4/30/2014

1. Name of participant _______________________ 2. PID _______________________
3. Grantee _______________________________________________________________
Host Agency Information
4. Name of host agency ____________________________________________________
5. Host agency mailing address
_____________________________________________________________________
a. Number and Street, Suite Number; or PO Box

_____________________________________________________________________
b. City

_____________________________________________________________________
c. State

d. ZIP code

6. FEIN___________________________________
7. Host agency type:

Not-for-profit

Government

7a. Date of host agency agreement _______________________ (MM/DD/YYYY)
7b. Date of host agency monitoring visit _______________________ (MM/DD/YYYY)
8. Host agency site name and location _________________________________________
8a. Host agency job codes: i ________
1. Art, Design, Entertainment,
Sports, and Media
2. Business and Financial
Operations
3. Community and Social Services
4. Computer and Mathematical
5. Construction, Installation, and
Repair
6. Education, Training, and Library
7. Farming, Fishing, and Forestry

ii ________

8. Food Preparation and Service
9. Healthcare
10. Legal
11. Maintenance and Custodial
12. Management

iii ________
15. Production, Assembly, Light
Industrial
16. Protective Service
17. Retail, Sales, and Related
18. Self-Employment
19. Transportation and Material
Moving

13. Office and Administrative
Support
14. Personal Care and Service

Authorized for Local Reproduction

ETA-9121
(Revised February 2012; replaces prior versions)

This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0040. Persons are not
required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this
collection of information required to obtain or retain benefits (PL 109-365 Sec 501-518) is estimated to average six (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 or any other aspect of this
collection, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Adult Services, Room S-4203,
200 Constitution Avenue, NW, Washington, DC 20210 (PRA Project 1205-0040).

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SCSEP Community Service Assignment Form

8b. Host agency continued availability

Available

Not available

Contact/Supervisor Information
9. Name of contact person _________________________________________________
10. Contact person’s mailing address if different from number 5
_____________________________________________________________________
a. Organization

_____________________________________________________________________
b. Number and Street, Suite Number; or PO Box
_____________________________________________________________________
c. City

_____________________________________________________________________
d. State

e. ZIP Code

11. Contact person’s title ___________________________________________________
11a. Contact person’s salutation

Mr.

Ms.

Dr.

12. Contact person’s phone number___________________________________________
12a. Contact person’s fax number ____________________________________________
12a1. Contact person’s cell phone number ______________________________________
12b. Contact person’s e-mail address __________________________________________

Complete fields 12c-12i if supervisor is different from contact person (number 9). If
supervisor is the same as contact person, skip to field 12j.
12c. Name of supervisor ____________________________________________________
12d. Supervisor’s mailing address if different from number 5
_____________________________________________________________________
a. Organization

_____________________________________________________________________
b. Number and Street, Suite Number; or PO Box
_____________________________________________________________________
c. City

_____________________________________________________________________
d. State

e. ZIP Code

12e. Supervisor’s title ______________________________________________________

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SCSEP Community Service Assignment Form
12f. Supervisor’s salutation

Mr.

Ms.

Dr.

12g. Supervisor’s phone number _____________________________________________
12h. Supervisor’s fax number ________________________________________________
12h1. Supervisor’s cell phone number _________________________________________
12i. Supervisor’s e-mail address ______________________________________________
12j. Funding source of supervisor or contact person/supervisor:
Federal
Non-federal $_______ (hourly rate) _______ (average hours per
week)
Assignment Information
13. Assignment date _______________________________ (MM/DD/YYYY)
14. Start assignment date ___________________________ (MM/DD/YYYY)
15. End date _____________________________________ (MM/DD/YYYY)
15a. Approved break in participation
Start date _________ (MM/DD/YYYY) Expected end date________ (MM/DD/YYYY)
Actual end date__________ (MM/DD/YYYY)
15b. Reason for approved break in participation
i. Family/health
ii. Personal

iii. Administrative
iv. Other (specify)________________

15c. Comments on approved break in participation

16. CSA wage (per hour) $ _________________________
16a. Number of hours per week assigned ____________
16b. Participant’s schedule

16c. Date of safety consultation with participant ________________ (MM/DD/YYYY)
16d. Does participant engage in volunteer work (in addition to
the community service assignment) during enrollment?
If yes, total number of volunteer activities _______________

Yes

No

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SCSEP Community Service Assignment Form
17. Community service assignment code_______________(Select only one code from
following lists)
Service to the general community includes the following activities:
G1. Education
G6. Environmental Quality
G2. Health and Hospitals
G7. Public Works & Transportation
G3. Housing and Home Rehabilitation
G8. Social Services
G4. Employment Assistance
G9. Legal
G5. Recreation, Parks, and Forests
G10. Financial
Service to the elderly community includes the following activities:
E1. Project Administration
E6. Nutrition Programs
E2. Health and Home Care
E7. Transportation
E3. Housing and Home Rehabilitation
E8. Outreach/Referral
E4. Employment Assistance
E9. Legal
E5. Recreation/Senior Centers
E10. Financial

G11.
G12.
G13.
G14.

Counseling
Conservation
Community Betterment
Other_______________

E11. Counseling
E12. Conservation
E13. Community Betterment
E14. Other_______________
________________________

18. Community service assignment title _______________________________________
18a. Participant’s job code___________
1. Art, Design, Entertainment,
Sports, and Media
2. Business and Financial
Operations
3. Community and Social Services
4. Computer and Mathematical
5. Construction, Installation, and
Repair
6. Education, Training, and Library
7. Farming, Fishing, and Forestry

8. Food Preparation and Service
9. Healthcare
10. Legal
11. Maintenance and Custodial
12. Management

15. Production, Assembly, Light
Industrial
16. Protective Service
17. Retail, Sales, and Related
18. Self-Employment
19. Transportation and Material
Moving

13. Office and Administrative
Support
14. Personal Care and Service

18b. Participant’s workers’ compensation code___________
19. Total hours paid in quarter
Quarter 1 ________________

Quarter 3 ________________

Quarter 2 ________________

Quarter 4 ________________

20. Types of training received (Check all that apply)
a. General training (basic skills)
b. Specialized training (specific job/industry)
c. On-the job-experience (OJE)

d. Other (specify)______________
e. None

21. Total hours of paid training received in quarter
Quarter 1 ________________

Quarter 3 ________________

Quarter 2 ________________

Quarter 4 ________________

22. Community service assignment comments

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SCSEP Community Service Assignment Form
Sub-Grantee Provided Training Information

Training Provider Information
23. Name of training provider or OJE employer _________________________________
24. Training provider or OJE employer mailing address
_____________________________________________________________________
a. Number and Street, Suite Number; or PO Box

_____________________________________________________________________
b. City

_____________________________________________________________________
c. State

d. ZIP code

25. Training provider continued availability

Available

Not available

Contact Person Information
26. Name of training provider or OJE employer contact person ____________________
27. Contact person’s mailing address if different from number 24
_____________________________________________________________________
a. Organization

_____________________________________________________________________
b. Number and Street, Suite Number; or PO Box
_____________________________________________________________________
c. City

_____________________________________________________________________
d. State

e. ZIP Code

28. Contact person’s title ___________________________________________________
29. Contact person’s salutation

Mr.

Ms.

Dr.

30. Contact person’s phone number___________________________________________
31. Contact person’s fax number _____________________________________________
31a. Contact person’s cell phone number ______________________________________
32. Contact person’s e-mail _________________________________________________

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SCSEP Community Service Assignment Form
Training Information
33. Types of training received (Check only one per training record)
a. General training (basic skills)
b. Specialized training (specific job/industry)
c. On-the job-experience (OJE)

d. Other (specify)_________________

34. Job code for which training is provided, if relevant ___________
1. Art, Design, Entertainment,
Sports, and Media
2. Business and Financial
Operations
3. Community and Social Services
4. Computer and Mathematical
5. Construction, Installation, and
Repair
6. Education, Training, and Library
7. Farming, Fishing, and Forestry

8. Food Preparation and Service
9. Healthcare
10. Legal
11. Maintenance and Custodial
12. Management

15. Production, Assembly, Light
Industrial
16. Protective Service
17. Retail, Sales, and Related
18. Self-Employment
19. Transportation and Material
Moving

13. Office and Administrative
Support
14. Personal Care and Service

35. Participant’s workers’ compensation code in training ___________
36. Start training date ______________________________ (MM/DD/YYYY)
37. End training date ______________________________ (MM/DD/YYYY)
38. Average number of hours of training per week___________
39. Average number of hours of community service per week during training_________
40. If OJE, wages paid by:
Sub-grantee

Employer and reimbursed by sub-grantee at rate of _____%

41. Training wage (per hour) $ ______________________
42. Total wages paid to participant or reimbursed to employer $ __________________
43. Total amount paid to training provider for provision of training (other than
reimbursement to employer) $ ________________
44. Training Comments

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