ETA 9123 SPARQ Exit Form

Senior Community Service Employment Program (SCSEP)

ETA 9123 Final_20180823.xlsx

OMB: 1205-0040

Document [xlsx]
Download: xlsx | pdf
OMB Control Number 1205-0040
ETA 9123 - Exit
Expiration Date: 08-31-2018


















DATA ELEMENT NAME DATA TYPE/ FIELD LENGTH DATA ELEMENT DEFINITIONS/INSTRUCTIONS CODE VALUE















Self Employed AN Record 1 if participant is self-employed
Record 0 if participant is not self-employed
1=Yes
0= No
















Termination Letter Date DT 8 Record the termination letter date YYYYMMDD















Signature of participant (Waiver Certification) AN 74 Record the signature of the participant on recertification
















Date of signing (participant) DT 8 Record the date on which the participant signed the exit form YYYYMMDD















Exit Comment AN 2000 Record exit comment
















Recipient Grantee AN Record recipient grantee name
















Recipient Sub-grantee AN Record recipient sub-grantee name
















Transfer Effective Date DT 8 Record the effective date of transfer YYYYMMDD















Reason For Transfer AN Record the reason for getting transfer 164 Result of approved swap of authorized positions
165 Participant was orphaned
166 Other administrative reason
167 Participant is moving
168 Other
















Recipient Grant IN Record the receipt Org Grant Number where participant case is getting transferred
















Reviewer Decision AN 2000 Record 1 if reviewer approved the transfer
Record 0 if reviewer did not approve the transfer
1=Yes
0= No
















Comments to Requester AN 2000 Record any additional comment
















Donor Concurrence IN 1 Record 1 if donor concur with the transfer
Record 0 if donor did not concur with the transfer
1=Yes
0= No
















Right of first refusal? IN 1 If the transfer request is initiated by the grantee for administrative reasons, the request must state that the transferred participant will receive: timely notice and explanation, the right of first refusal for 90 days, and the application of the more liberal of the two grantees’ IDL policy for 90 days.

Record 1 if the transfer request is initiated by the grantee for administrative reasons
Record 0 if the transfer request is not initiated by the grantee for administrative reasons
1=Yes
0= No
















Program Office Concurrence IN 1 If the transfer request is initiated by the grantee for administrative reasons, the National Office must concur.

Record 1 if program office concurred
Record 0 if program office did not concurred
1=Yes
0= No
















Is the transfer due to a swap of positions between grantees? IN 1 Record 1 if transfer is due to a swap of positions between grantees
Record 0 if transfer is not due to a swap of position between grantees
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 3 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.















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