Standard Job Corps reporting forms

OMB Control No. 1205-0219
Expires xx/xx/xxxx

JOB CORPS DEMONSTRATION PROJECT: APPLICANT DATA
Program Name:___________________________________
Center/Location Name:_____________________
Applicant ID:______________
SSN:____________________________
Date Application Completed: _____________ Most Recent Date Application Modified: _____________
PRIMARY ADDRESS:
STATE:___________

COUNTY:____________

ZIP CODE:______________

APPLICANT DEMOGRAPHICS:
DOB:________________
GENDER:  Male
 Female
ETHNICITY:
 Hispanic/Latino
 Not Hispanic/Latino  Did not self-identify ethnicity
RACE: (select all that apply)
 American Indian / Alaska Native
 Asian
 White
 Native Hawaiian / Other Pacific Islander
 Black / African American  Did not self-identify race
ACADEMIC AND EMPLOYMENT BACKGROUND AT TIME OF APPLICATION:
HIGHEST SCHOOL GRADE COMPLETED: ___________
HIGHEST EDUCATIONAL LEVEL COMPLETED:  None  HSD  HSE  Certificate of Attendance/Completion of IEP
 Some Post-secondary  AA/AS  Post-secondary Technical/Vocational Certificate  Other:__________________
FILED UNEMPLOYMENT COMPENSATION CLAIM AND IS ELIGIBLE FOR BENEFITS:  YES  NO
Referral by: (select all that apply)  RESEA
 WPRS
 Other:
__________________________
 Exhausted Benefits
 Exempt from Work Search Requirements
RECEIVED PUBLIC ASSISTANCE IN LAST SIX MONTHS: (select all that apply)
 Temporary Assistance for Needy Families (TANF)
 SSI  SSDI
 TICKET TO WORK HOLDER
 General Assistance (GA) (State/local government) or Refugee Cash Assistance (RCA)
ADDITIONAL YOUTH CHARACTERISTICS AT PROGRAM APPLICATION: (select all that apply)
 Foster Care
 Homeless
 Runaway Youth
 Low income Status
 English Language Learner  Basic Skills Deficient/Low Levels of Literacy
Cultural Barriers:  Yes  No  Did Not Self-Disclose
Single Parent:  Yes  No  Did Not Self-Disclose
VETERAN STATUS:
SERVED OR SERVING ON ACTIVE DUTY IN U.S. ARMED FORCES:  YES  NO  DID NOT SELF-DISCLOSE
DATE OF SEPARATION: _____________
LENGTH OF SERVICE:
 Served 180 days or less on active duty  Served more than 180 days on active duty
SERVICE TYPE:
 Served on active duty during war/campaign/expedition, and  Served as part of a reserve component
DISCHARGE TYPE:  Honorable
 Other Than Honorable
 General
 Bad Conduct
 Dishonorable
 Other:__________________
OTHER: (select all that apply)
 Discharged from active duty for a service-connected disability
 Entitled to compensation regardless of rating (including 0%), or entitled but receives military retirement pay,
under laws administered by DVA
 Entitled to compensation, or entitled but receives military retirement pay, under laws administered by DVA
for a disability rated at (i) 30% or more OR (ii) 10% or 20% if determined to have a serious employment handicap
 Homeless veteran
APPLICANT’S SPOUSE SERVED ON ACTIVE DUTY IN U.S. ARMED FORCES:  YES  NO
 Spouse died on active duty or of service-related disability

OMB Control No. 1205-0219
Expires xx/xx/xxxx
 Spouse missing in action for 90 or more days at time of application OR Spouse captured in line of duty by
hostile force, or forcibly detained/interned in line of duty by foreign government or power for 90 or more days
at time of application
 Spouse has a total, permanent disability from a service-connected disability or died with such a disability
CURRENTLY SERVING IN U.S. ARMED FORCES AND IS WITHIN 12 MONTHS OF SEPARATION OR 24 MONTHS OF
RETIREMENT:  YES  NO
DISABILITY STATUS:
APPLICANT DISCLOSED A DISABILITY:  YES  NO  DID NOT SELF-IDENTIFY
DISABILITY TYPE: (select all that apply)  Physical/Chronic Health Condition  Physical/Mobility Impairment
 Mental or Psychiatric Disability
 Vision-related disability
 Hearing-related disability
 Learning Disability  Cognitive/Intellectual disability
 Participant did not disclose type of disability
APPLICANT RECEIVED SERVICES FUNDED BY: (select all that apply)
 SDDA
 LSMHA
 State Medicaid HCBS Waiver
 No Services Funded By These Sources
TYPE OF WORK SETTING: (select all that apply)
 Working in competitive, integrated employment (CIE)
 Working in group supported employment
 Working in a sheltered workshop  Previously employed in supported employment  Not Currently Employed
APPLICANT RECEIVED CUSTOMIZED EMPLOYMENT SERVICES (CES):  YES
 NO
Type of CES: (select one)
 Discovery assessment services
 Developed a customized employment search plan
 Employer negotiation services
 Secured employment as a result of receiving customized employment services and received extended
support services
FINANCIAL CAPABILITY: (select all that apply)
 Received benefit planning services  Received financial capability/asset development services  None

OMB Control No. 1205-0219
Expires xx/xx/xxxx

JOB CORPS DEMONSTRATION PROJECT: ENROLLEE DATA
Program Name:____________________________________ Center/Location Name:_____________________
Applicant ID:______________
SSN:____________________________
Date of Enrollment: ___________________
Date of Exit: ___________________
EDUCATION SERVICES RECEIVED:
ENROLLED IN: (select all that apply)  NONE  SECONDARY PROGRAM
 POST-SECONDARY PROGRAM
PROGRAM #1: START DATE:__________
DATE CREDENTIAL ATTAINED: _________
CREDENTIAL TYPE:  HSD  HSE  AA/AS  Other: ________________
PROGRAM #2: START DATE:__________
DATE CREDENTIAL ATTAINED: _________
CREDENTIAL TYPE:  HSD  HSE  AA/AS  Other: ________________
PROGRAM #3: START DATE:__________
DATE CREDENTIAL ATTAINED: _________
CREDENTIAL TYPE:  HSD  HSE  AA/AS  Other: ________________
ACADEMIC MILESTONES ACHIEVED:
Date of most recent transcript/report card from:
 post-secondary program with 12+ credit hours in a semester (FT) or over 2 semesters (PT) meeting
state unit’s academic standards: Date: ________________
 secondary program meeting state unit’s academic standards: Date: ________________
Total Academic Hours Earned since Program Start: ____________
TRAINING SERVICES RECEIVED:
ENTERED TRAINING PROGRAM:
 YES
 NO
 TRAINING # 1: TYPE:___________________ START DATE: _____________
 TRAINING # 2: TYPE:___________________ START DATE: _____________
 TRAINING # 3: TYPE:___________________ START DATE: _____________

COMPLETION DATE: _____________
COMPLETION DATE: _____________
COMPLETION DATE: _____________

TRAINING-RELATED CREDENTIALS ATTAINED:
Record Industry-Recognized Credential or Certification, Certificate of Completion of a Registered Apprenticeship, or a
State or Federal-recognized license attained during program enrollment
 Credential #1: DATE: ___________ TYPE:  Licensure  Certificate  Certification  Other:_______________
 Credential #2: DATE: ___________ TYPE:  Licensure  Certificate  Certification  Other:_______________
 Credential #3: DATE: ___________ TYPE:  Licensure  Certificate  Certification  Other:_______________
TRAINING MILESTONES ACHIEVED:
 Completed an exam that is required for a particular occupation: DATE: ___________
 Progress in attaining technical or occupational skills as evidenced by trade-related benchmarks such as knowledgebased exams. DATE: ______________
 A satisfactory or better progress report towards established milestones from an employer/training provider who is
providing training (e.g., completion of on-the-job training (OJT), completion of one year of a registered apprenticeship
program, etc.). DATE: _____________
EFL GAINS:
READING:
CATEGORY OF ASSESSMENT:  ABE
 ESL
TEST TYPE:
 TABE 11/12
 CASAS
 OTHER:_________
DATE OF INITIAL TEST: ___________
INITIAL TEST SCORE: _______________ INITIAL TEST EFL:________
DATE OF POST-TEST: ___________
POST-TEST SCORE: _______________ POST-TEST EFL:________
MATH:

OMB Control No. 1205-0219
Expires xx/xx/xxxx
CATEGORY OF ASSESSMENT:  ABE
TEST TYPE:
 TABE 11/12
DATE OF INITIAL TEST: ___________
DATE OF POST-TEST: ___________
OTHER:
CATEGORY OF ASSESSMENT:  ABE
TEST TYPE:
 TABE 11/12
DATE OF INITIAL TEST: __________
DATE OF POST-TEST: __________

 ESL
 CASAS
 OTHER:_________
INITIAL TEST SCORE: _______________ INITIAL TEST EFL:________
POST-TEST SCORE: _______________ POST-TEST EFL:________
 ESL
 CASAS
 OTHER:_________
INITIAL TEST SCORE: _______________ INITIAL TEST EFL:________
POST-TEST SCORE: _______________ POST-TEST EFL:________

EXIT STATUS:
 Graduate  Former Enrollee
 Other:___________
 Program Completer  Program Non-Completer
EXIT REASON:
 Institutionalized
 Health/Medical
 Deceased
 Reserve Forces called to Active Duty
 Foster Care  Ineligible  Criminal Offender  None of the above

OMB Control No. 1205-0219
Expires xx/xx/xxxx

JOB CORPS DEMONSTRATION PROJECT: POST-SEPARATION DATA
Program Name:____________________________________ Center/Location Name:_____________________
Applicant ID:______________
SSN:____________________________
POST-SEPARATION PLACEMENT:
Qualifying Student Placement:
One Full Time Job
Two Full Time Jobs
One Part Time Job
Two Part Time Jobs
Armed Forces

Registered Apprentice Full Time Job
Full Time Job/College Combo
Part Time Job/College Combo
College
Post-Secondary School/Training

Other Training Program
OJT/Paid Employment
High School Diploma (HSD) Program
High School Equivalency(HSE) Program
Not Placed

Job Training Match:  YES
 NO
Hourly Wage at Placement: $_______.____
Hourly Wage at Six Months After Placement: $_______.____
Hourly Wage at 12 Months After Placement: $_______.____
Date Placed:__________
FIRST QUARTER AFTER EXIT:
Entered Employment:
 Military  Registered Apprenticeship  Other unsubsidized employment
 Not employed
Date Entered Employment:_______________
Date Exited Employment (if applicable):___________________
Data source:
 UI Wage Data
 Federal Employment Records (OPM, USPS)  Military Employment Records (DOD)
 Non UI verification  Not employed
Quarterly Earnings: $_________________
Education Secondary/Post-secondary Degree:
 Enrolled in Post-Secondary Education/Training
 Attained HSD
 Attained HSE
 Attained AA/AS

Date Enrolled: _______________
Date Attained: _______________
Date Attained: _______________
Date Attained: _______________

SECOND QUARTER AFTER EXIT:
Entered Employment:
 Military  Registered Apprenticeship  Other unsubsidized employment
 Not employed
Date Entered Employment:_______________
Date Exited Employment (if applicable):___________________
Data source:
 UI Wage Data
 Federal Employment Records (OPM, USPS)  Military Employment Records (DOD)
 Non UI verification  Not employed
Quarterly Earnings: $_________________
Entered Education/Training program:
 None
 Occupational Skills Training  Postsecondary Education
Date Entered Education/Training program:_______________
Education Secondary/Post-secondary Degree:

 Secondary Education

OMB Control No. 1205-0219
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 Enrolled in Post-Secondary Education/Training
 Attained HSD
 Attained HSE
 Attained AA/AS

Date Enrolled: _______________
Date Attained: _______________
Date Attained: _______________
Date Attained: _______________

THIRD QUARTER AFTER EXIT:
Entered Employment:
 Military  Registered Apprenticeship  Other unsubsidized employment
 Not employed
Date Entered Employment:_______________
Date Exited Employment (if applicable):___________________
Data source:
 UI Wage Data
 Federal Employment Records (OPM, USPS)  Military Employment Records (DOD)
 Non UI verification  Not employed
Quarterly Earnings: $_________________
Education Secondary/Post-secondary Degree:
 Enrolled in Post-Secondary Education/Training
 Attained HSD
 Attained HSE
 Attained AA/AS

Date Enrolled: _______________
Date Attained: _______________
Date Attained: _______________
Date Attained: _______________

FOURTH QUARTER AFTER EXIT:
Entered Employment:
 Military  Registered Apprenticeship  Other unsubsidized employment
 Not employed
Date Entered Employment:_______________
Date Exited Employment (if applicable):___________________
Data source:
 UI Wage Data
 Federal Employment Records (OPM, USPS)  Military Employment Records (DOD)
 Non UI verification  Not employed
Quarterly Earnings: $_________________
Employed by Same Employer in Q2 and Q4:  YES
 NO
Entered Education/Training program:
 None
 Occupational Skills Training  Postsecondary Education
Date Entered Education/Training program:_______________
Education Secondary/Post-secondary Degree:
 Enrolled in Post-Secondary Education/Training
 Attained HSD
 Attained HSE
 Attained AA/AS

 Secondary Education

Date Enrolled: _______________
Date Attained: _______________
Date Attained: _______________
Date Attained: _______________

Public Burden Statement - Persons are not required to respond to this collection of information unless it displays a currently valid
OMB control number and expiration date. Public reporting burden for this collection of information, which is required to obtain or
retain benefits (29 USC 2881), is estimated to average 1 hour per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and the completing and reviewing the collection of information.
This information collection is for program management and Congressional reporting purposes. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S.
Department of Labor, Office of Job Corps. Room N-4507, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0219).