Form ETA-9085 INDIAN AND NATIVE AMERICAN YOUTH PROGRAM ANNUAL / SEMI-A

INDIAN AND NATIVE AMERICAN YOUTH
PROGRAM ANNUAL / SEMI-ANNUAL REPORT
OMB No. 1205-0422
Expires: 01/31/2020

SECTION I - Grantee Identifying Information
Grantee Name and Address:

Grant Number:
Report End Date:

Previous Period
(A)

Current Period
(B)

SECTION II - Participant / Exiter Summary - [Enter participants who enrolled in the program and exited during the program year.]
1. Total Participants
a. Participation in Summer Employment
2. Total Exiters
a. Summer Employment Exiters
3. Total Current Participants
SECTION III - Participant Characteristics Summary - [Enter characteristics of participants at enrollment.]
4. Male
5. Female
6. High School / Pre-High School Student
7. High School Graduate or Equivalent
8. Post High School Student
9. School Dropout
10. Pregnant and/or Parenting Youth
11. Offender
12. Foster Child
13. Public Assistance Recipient
14. Basic Skills Deficiency
15. Individual With Disability
16. In-school youth
17. Out-of-school youth
18. 14 - 18
19. 19 - 21
20. 22 - 24 (Recovery Act Participants Only)
21. Eligible Veterans

Program to Date
(C)

SECTION IV - Participant Goals and/or Attainments Summary - [Enter goals attained after receiving program services.]
22. Completed Work Readiness
23. Completed Internship or Vocational Exploration Program
24. Completed Career Assesment
25. Entered Unsubsidized Employment (Including Military)
26. Remained in School
27. Returned to School Full Time
28. Enrolled in Job Corps
29. Improved Basic Skills by at Least Two Grade Levels
30. Attained High School Diploma
31. Attained GED
32. Completed Occupational Skills Training
33. Completed Leadership Skills Training
34. Entered Other (Non-Supplemental Youth) Training Program
35. Successful Completion of Summer Employment
Previous Period
(A)
Performance Items
Value

Numerator
Denominator

Current Period
(B)
Value

Program-to-Date
(C)

Numerator

Value

Denominator

Numerator
Denominator

SECTION V - Performance Outcomes / Performance
36. Attainment of Two or More Goals

37. Educational Attainment for Dropouts

Remarks:

Certification: I certify that to the best of my knowledge and belief that this report is correct and complete for the purpose set forth in the Grant Agreement.
Grantee Name:
Phone No:

Email:

Certifying Official:

This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0422. Persons are not required to respond to this collection of information unless it displays a currently
valid OMB number and expiration date. Public reporting burden for this collection of information, which is required for obtaining or retaining benefits (PL 105-220, Sec. 166), is estimated to average 2 hours per
response, including time for reviewing instructions, searching existing data sources, gathering and reviewing the collection of information. The reason for the collection of information is general program oversight,
evaluation and performance assessment. Send comments regarding this burden to the U.S. Department of Labor, Employment and Training Administration, Indian and Native Americans Program, 200 Constitution
Avenue, NW, Room N4209, Washington, D.C. 20210.

ETA Form 9085 (September 2019)