ETA 9121 SPARQ Community Service Form

Senior Community Service Employment Program (SCSEP)

ETA 9121 Final_20180823.xlsx

OMB: 1205-0040

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Overview

ETA 9121
Services


Sheet 1: ETA 9121

OMB Control Number 1205-0040
ETA 9121 - Community Service Assignment
Expiration Date: 08-31-2018



DATA ELEMENT NAME DATA TYPE/ FIELD LENGTH DATA ELEMENT DEFINITIONS/INSTRUCTIONS CODE VALUE
Assignment IN Links the service being entered to a particular Assignment

Host Agency AN Record host agency

Type IN Select a service Type Review Services Tab
Grant Number IN System-generated

Host Agency Name AN 225 Record Host Agency Organization Name

Address Line 1 AN 225 Record the Host Agency Organization Address 1

Address Line 2 AN 225 Record the Host Agency Organization Address 2

City AN 225 Record the Host Agency Organization City

State AN 2 Record the Host Agency Organization State

Zip IN 5 Record the Host Agency Organization Zip 00000
FEIN IN Record FEIN

Host Agency Type IN Record Agency Type 69 Not-for-profit
70 Government

Host Agency Agreement Date DT 8 Record Agency Agreement Date YYYYMMDD
Host Agency Monitoring Visit Date DT 8 Record Agency Monitoring Visit Date YYYYMMDD
Host agency's site name and location AN 225 Record the host agency's site name and location

Host agency job codes AN 225 Record Agency job code 1

Host agency job codes AN 225 Record Agency job code 2

Host agency job codes AN 225 Record Agency job code 3

Host Agency Continued Availability IN 1 Record 1 for active if host agency wishes to continue to participate in the program or if grantee/sub-grantee wishes to continue working with this host agency
Record 2 for inactive if host agency no longer wishes to continue to participate in the program or if grantee/sub-grantee no longer wishes to continue working with the host agency
1 = Active
2 = Not Active

Contact First Name AN 26 Record host agency contact first name

Contact Last Name AN 26 Record host agency contact last name

Contact Address if different than the host agency address Checkbox Record Contact Address if different than host agency address

Survey Contact IN Record the participant available survey contact detail

Address Line 1 AN 225 Record the Host Agency Organization Contact Address 1

Address Line 2 AN 225 Record the Host Agency Organization Contact Address 2

City AN 225 Record the Host Agency Organization Contact City

State AN 2 Record the Host Agency Organization Contact State

Zip IN 5 Record the Host Agency Organization Contact Zip 00000
County AN 225 Record the Host Agency Organization Contact County

Title AN 225 Record the host agency contact person's title

Phone Number IN 10 Record the host agency contact person's phone number

Fax Number IN 10 Record the host agency contact person's fax number

Cell Phone Number IN 10 Record the host agency contact person's cell phone number

E-mail AN 26 Record the host agency contact person's email address

Supervisor AN 26 Record the host agency supervisor's name if different than contact

Host Agency Supervisor's Organization AN 225 Record the host agency supervisor's organization

Address Line 1 AN 225 Record the Host Agency Host Agency supervisor's Address 1

Address Line 2 AN 225 Record the Host Agency supervisor's Address 2

City AN 225 Record the Host Agency supervisor's City

State AN 2 Record the Host Agency supervisor's State

Zip IN 5 Record the Host Agency supervisor's Zip 00000
County AN 225 Record the Host Agency supervisor's County

Title AN 74 Record the host agency supervisor's title

Supervisor's Salutation AN 1 Record the host agency Supervisor's salutation 1= Mr.
2= Ms.
3= Dr.

Phone number IN 10 Record the host agency Supervisor's phone number

Fax number IN 10 Record the host agency Supervisor's fax number

Cell phone number IN 10 Record the host agency Supervisor's cell phone number

E-mail AN 26 Record the host agency Supervisor's email address

Funding Source Type IN Record 1 if funding source type is federal
Record 2 if funding source type is non-federal
1=Federal
2= Non-federal

Supervisor's Hourly Wage DE 3.2 Record supervisor's hourly wage 0
Supervisor's Number of Hours per week IN Record supervisor's number of hours per week

Assignment Date DT 8 Record assignment date YYYYMMDD
Assignment Start Date DT 8 Record assignment start date YYYYMMDD
Assignment End Date DT 8 Record assignment end date YYYYMMDD
Specify Other Reason for Approved Break AN 225 Specify other reason for approved break

Approved break Comment AN 2000 Record approved break comment

Participant's Number of Hours per week IN 3 Record participant's number of hours per week 000
Participant's Schedule AN 2000 Record participant schedule

Safety Consultation Date DT 8 Record consultation date YYYYMMDD
Community Service Assignment Code Type Radio Button
General
Elderly

Community Service Assignment Code Dropdown Record community service assignment code 94G1. Education
95G2. Health and Hospitals
96G3. Housing and Home Rehabilitation
97G4. Employment Assistance
98G5. Recreation, Parks, and Forests
99G6. Environmental Quality
100G7. Public Works & Transportation
101G8. Social Services
102G9. Legal
103G10. Financial
104G11. Counseling
105G12. Conservation
106G13. Community Betterment
107G14. Other
108E1. SCSEP Project Administration
109E2. Health and Home Care
110E3. Housing and Home Rehabilitation
111E4. Employment Assistance
112E5. Recreation/Senior Centers
113E6. Nutrition Programs
114E7. Transportation
115E8. Outreach/Referral
116E9. Legal
117E10. Financial
118E11. Counseling
119E12. Conservation
120E13. Community Betterment
121E14. Other

Specify Other Community Service Assignment Code AN 225 Specify other community service assignment code

Community Service Assignment Title AN 225 Record community service assignment title

Participant's Job Code Dropdown Select Participant Job Code Review Participant Job Code Tab
Participant's Workers' Compensation Code at Host Agency AN Record participant's workers' compensation code

Type Dropdown Select type of services Review Service Tab
Start Date DT 8 Record supportive service start date YYYYMMDD
Specify Other Provider of Supportive Services AN 225 Specify other provider of supportive services

Assignment comment AN 2000 Record assignment comments

Service Provider Name AN 225 Record service provider name

Address Line 1 AN 225 Record the service provider contact address 1

Address Line 2 AN 225 Record the service provider contact address 2

City AN 225 Record the service provider contact City

State AN 2 Record the service provider contact State

Zip IN 5 Record the service provider contact Zip 00000
Training provider continued availability IN 1 Record 1 for active if training provider wishes to continue to participate in the program or if grantee/sub-grantee wishes to continue working with this training provider
Record 2 for inactive if training provider no longer wishes to continue to participate in the program or if grantee/sub-grantee no longer wishes to continue working with the training provider
1 = Active
0 = Inactive

Contact First Name AN 26 Record service provider contact first name

Contact Last Name AN 26 Record service provider contact last name

Contact person's address AN 225 Record contact person address if different than host agency address

Address Line 1 AN 225 Record the Host Agency Organization Contact Address 1

Address Line 2 AN 225 Record the Host Agency Organization Contact Address 2

City AN 225 Record the Host Agency Organization Contact City

State AN 2 Record the Host Agency Organization Contact State

Zip IN 5 Record the Host Agency Organization Contact Zip 00000
Salutation IN 1 Record the host agency contact person's salutation. 1= Mr.
2= Ms.
3= Dr.

Contact IN 10 Record the host agency contact person's phone number

Ext. IN 10 Record the host agency contact person's phone extension

Contact AN 26 Record the host agency contact person's email address

Occupation Code IN Enter the 8 digit O*Net 4.0 (or later versions) code that best describes the training occupation for which the participant received training services.
Leave blank if occupational code is not available or not known.

Additional Notes: If all 8 digits of the occupational skills code are not collected, record as many digits as are available. If the participant receives multiple training services, use the occupational skills training code for the most recent training.
00000000
Participant's Workers compensation code in training AN 225 Record participant's workers' compensation code

Start Date DT 8 Record training service start date YYYYMMDD
Expected End Date DT 8 Service End Date YYYYMMDD
Average number of hours of skill training per week IN 3 Record the average number of hours of skill training per week outside of community service assignment

Average number of hours of community service per week during training IN 3 Record the average number of hours of community service per week during training

If OJE, wages paid by IN 1 Record 1 if OJE was paid by the grantee
Record 2 if OJE was paid by reimbursing the employer
1= Grantee
2= Employer Reimbursement

If OJE is Reimbursement, percentage of rate IN 3 Record the percentage of reimbursement rate if OJE is reimbursed

Training Hourly wage DE 6.2 Record the participant’s training hourly wage
Leave blank if the participant was not enrolled in training
000000.00
Total wages paid to participant or reimbursed to employer for OJE DE 6.2 Record wages paid to participant or reimbursed to employer for OJE 000000.00
Total paid to training provider DE 6.2 Record total amount paid to training provider for skill training 000000.00
Service Comment AN 2000 Provide a brief description of service provided to the participant

Ext. IN 10 Record the host agency contact person's phone ext.

Participant Name AN 26 Record participant name

Unique Individual Identifier AN System-generated

Organization AN 225 Record organization Name

Program Year IN 4
XXXX
Status Dropdown System-selection (pending; pending eligibility approval; eligible; active; exited-in follow-up; exited-closed)

Enrollment From DT 8 System-selection YYYYMMDD
Enrollment To DT 8 System-selection YYYYMMDD
Exit From DT 8 System-selection YYYYMMDD
Exit To DT 8 System-selection YYYYMMDD
Service Provider IN Search available service provider in system

Training Completed? IN 1 Record 1 if the participant completed approved training
Record 0 if the participant did not complete training (withdrew). Leave blank if the participant did not receive a first training service or this data element does not apply to the participant
1 = Yes
0 = No

Cost of Service DE 6.2 Record the participant cost of service 000000.00
Ext. AN 10 Record phone extension

Is Documentation Provided IN 1 Record 1 if documentation for approved break is provided
Record 0 if documentation for approved break is not provided
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 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 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.

Sheet 2: Services

Category Type
Career Services Assessment of Skill Level and Other Service Needs
Career Services Orientation
Career Services Work-related Safety Training
Career Services Job Clubs
Career Services Job Fairs
Career Services Job Placement and Job Search Assistance
Career Services Career Counseling
Career Services Health, Wellness, and Nutrition (e.g. RX, Medical needs, and Meals on Wheels)
Career Services Counseling (e.g. Grandparents raising Grandchildren)
Career Services Benefit Check-up Counseling
Career Services Civic Engagement
Career Services Computer Based Training via online modules (Non-Industry recognized certificate(s))
Career Services Individual Employment Plan (IEP)
Career Services Individual Counseling (e.g. Legal Service and Substance Abuse)
Career Services Career Planning (e.g. Resume and interviewing assistance)
Career Services Financial Literacy Services
Career Services Tutoring, Study Skills Training, Dropout Prevention
Career Services Other Counseling (Specify)
Career Services Test of English as a Foreign Language
(TOEFL)
Career Services Test for Adult Basic Education (TABE) /Comprehensive Adult Student Assessment Systems (CASAS)
Community Service Assignment Soft Skills (e.g. Hygiene, Communications skills, and Social interactions)
Community Service Assignment Short-term Prevocational Services
Community Service Assignment Programs that combine workplace training with related instruction
Community Service Assignment Skills upgrading and retraining
Community Service Assignment Job Readiness Training
Training Occupational Skills Training
Training On-the-Job-Experience (OJE)
Training Apprenticeship Training
Training Entrepreneurship Training
Training Digital Literacy Training
Training Educational Remediation and Literacy Training (i.e. Adult Basic Education, Alternative Secondary School, GED or other High School Equivalent Credential)
Training Limited English Proficiency (ESL)
Referral One-Stop (Known as American Job Center)
Referral Job Clubs/Fairs
Referral Job Placement and Job Search Assistance
Referral Job Interviews
Referral Social Services or Other Public Assistance
Referral Another SCSEP project
Referral Department of Veterans Affairs (i.e. Vocational Rehabilitation and Employment Program, and other VA Services)
Referral Federal Training
Referral Health and Human Services Programs
Referral Other Federal/State Assistance Services (specify)
Referral Others (Substance Abuse, Mental Health, Legal Services, etc.) (Specify)
Supportive Service Transportation Assistance
Supportive Service Work Attire (i.e. Uniforms and badges)
Supportive Service Work Related Tools
Supportive Service Employment (Job or Training) Related Fees
Supportive Service Eye Glasses, etc.
Supportive Service Meal Assistance
Supportive Service Housing (i.e. Temporary Housing Assistance)
Supportive Service Dependent care (i.e. Child or Adult Care Assistance)
Supportive Service Health and medical services (i.e. RX and Annual Physical)
Supportive Service Needs-related payment, such as utilities or food
Supportive Service Special job-related or personal counseling (received at follow-up)
Supportive Service Educational Testing Fees
Supportive Service Occupational Licensing Fees
Supportive Service Educational Assistance with Books, School Supplies, Other Fees
Supportive Service Others (Specify)
Follow-Up Services Help Participant Get Another Job
Follow-Up Services Intervention with Employer
Follow-Up Services Counsel Participant on Job-Related Issues
Follow-Up Services Request for Supplemental Information
Follow-Up Services Supportive Services
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