Form ETA-9084 Comprehensive Services Quarterly Performance Report

ETA Form 9084 - Comprehensive Services Quarterly Performance Report
OMB No: 1205-0422
Expires: 01/31/2021

A. GRANTEE IDENTIFYING INFORMATION
1. Grantee Name:

2. Grant Number:

3. Program/Project Name:
4. Grantee Address:
City:

5. Report Quarter End Date:
State:

Performance Items
B. CUSTOMER SUMMARY INFORMATION
1. Total Exiters
2. Core Services: Self-Services only
3. Total Participants Served
4. New Participants Served
4a. Male
4b. Female
4c. In-School, H.S. or less
4d. In-School, Post H.S.
4e. Not Attending School; H.S. Graduate
4f. Not Attending School; H.S. Dropout
4g. Offender/Criminal Justice Barrier
4h. Individuals with a Disability
4i. Public Assistance Recipient
4j. Basic Skills Deficiency
4k. Limited English Proficient
4l. Eligible Veterans
4m. Eligible Veteran's Spouse
4n. Homeless
4o. Long-term Unemployed
4p. Multiple Barriers
C. CUSTOMER SERVICES AND ACTIVITIES
1. Core Services
2. Intensive Services
2a. Work Experience
3. Training Services
3a. CRT: Basic Skills or Literacy Activities
3b. CRT: Occupational Skills Training
3c. On-the-Job Training
3d. Entrepreneurial and Small Business Training
3e. Other Training Services

ZIP Code:

Previous
Quarter
(A)

6. Report Due Date:

Current
Quarter
(B)

Cumulative
4-Qtr Period
(C)

D. PERFORMANCE RESULTS
Outcome
(Cumulative 4-Quarter Results Tabulated for Exit Cohort Shown)

Value

numerator
denominator

Value

numerator
denominator

Value

numerator
denominator

1. Entered Employment Rate
(xx/xx/xx to xx/xx/xx)
2. Retention Rate
(xx/xx/xx to xx/xx/xx)
3. Average Earnings
(xx/xx/xx to xx/xx/xx)
4. Education (Credential) Measure
(xx/xx/xx to xx/xx/x)

E. REPORT CERTIFICATION/ADDITIONAL COMMENTS
1. Report Comments/Narrative:

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.

2. Name of Grantee Certifying Official/Title

3. Telephone Number:

4. Email Address:

ETA Form 9084 (September 2019)