Form ETA 9120, ETA 9121 ETA 9120, ETA 9121 SPARQ Data Collection Forms

SCSEP Participant Form

OMB Approval Number: 1205-0040
Expiration Date: 11/30/2021

Participant Information
1. Last name ______________________

2. First name_________________________

3. Middle initial __________

4. Social Security # ___________________

4a. Participant ID ____________

5. Home phone (____) ________________

5a. Cell phone (____) ________________
6. Mailing address
_____________________________________________________________________
a. Number and Street, Apt. Number; or PO Box

_____________________________________________________________________
_____________________________________________________________________
b. City

c. State

_____________________________________________________________________
d. ZIP Code

e. County

6a. Participant’s e-mail address ______________________________________________
6b. Emergency contact: Name_________________ Phone (____) _________________
Relationship ________________________________
7. State of residence if different from mailing address ____________________________
8. Homeless

Yes

No

8a. Urban/rural

Urban

Rural

9. Application date for enrollment or re-enrollment ______________(MM/DD/YYYY)
Eligibility Information
10. Date of birth________________(MM/DD/YYYY) 11. Number in family______
12. Receiving public assistance? (Check as many as apply)
a. No
c. TANF
e. Suppl. Nutrition Assistance (SNAP)
g. Social Security Disability (SSDI)
(specify)______________________

b. Supplemental Security Income (SSI)
d. State or local welfare (General Assistance)
f. Subsidized housing
h. Other

This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0040. Persons are not
required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this
collection of information required to obtain or retain benefits (PL 109-365 Sec 501-518) is estimated to average twelve (12) 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 or any other
aspect of this collection, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workforce
Investment, Room C-4510, 200 Constitution Avenue, NW, Washington, DC 20210 (PRA Project 1205-0040).

ETA-9120
(Rev. 2/12/2021)
1

SCSEP Participant Form
13. Employed prior to participation?
i. Employed
ii. Employed, but with notice of termination

iii. Not employed

14. Total includable family income (12-month or 6-month annualized)
$______________
15. Family income at or below 100% of poverty level?

Yes

No

16. Formerly a participant in any SCSEP project?

Yes

No

17. *Transferred from another project?
Yes
No
If yes, specify prior grantee code _____________________________________
Date of transfer ____________________________

17a. *Change of sub-grantee?
Yes
No
If yes, specify prior sub-grantee code __________________________________
Date of change __________________________
Other Personal Characteristics and Information
18. Gender

Male

Female

Did not voluntarily report

19. Ethnicity: Hispanic, Latino, or Spanish origin?
Yes

No

Did not voluntarily report

20. Race (Check as many as apply)
a. American Indian or Alaskan Native
c. Black, African American
e. White

b. Asian
d. Native Hawaiian/Pacific Islander
f. Did not voluntarily report

21. Education ________ last grade completed (Select one code from following list)
00=no grade school
1-11 years of school
A11=completed 12 years of
school but no HS diploma
12=HS diploma

88=GED or certificate of equivalency for HS
13-15 years of school completed (1-3 years of college)
16=BA/BS or equivalent
17=education beyond a bachelor's degree
18=master's degree

22. Limited English Proficiency (LEP)

Yes

19=doctoral degree
21=vocational/technical
degree
22=associate's degree

No

*No data entry in SPARQ. Field is system-generated.

2

SCSEP Participant Form
23. If LEP, please specify primary language _____ (Select one code from following list)
10. Amharic
11. Arabic
12. Armenian
13. Bosnian
14. Cantonese (Yue)
15. French
16. French Creole
17. German
18. Greek
19. Gujarathi

20. Hebrew
21. Hindi
22. Miao (Hmong)
23. Italian
24. Hungarian
25. Ilocano
26. Japanese
27. Korean
28. Laotian
29. Mandarin

24. Low literacy skills?

30. Mon-Khmer (Cambodian)
31. Navajo
32. Persian (including Dari)
33. Polish
34. Portuguese
35. Punjabi
36. Russian
37. Samoan
38. Serbo-Croatian
39. Somali

Yes

40. Spanish
41. Tagalog
42. Thai
43. Urdu
44. Vietnamese
45. Yiddish
46. Other_____
____________

No

25. Veteran (or eligible spouse of veteran)?
a. Veteran
b. Eligible spouse of veteran
If veteran, post-9/11 era veteran?
Yes
26. Disability?
Yes, self-report
Yes, documentation

c. Non-covered person
No

No
Did not voluntarily report

27. At risk of homelessness?

Yes

No

28. Displaced homemaker?

Yes

No

29. Failed to find employment after using WIA Title I?
30. Low employment prospects?
30a. Formerly incarcerated?

Yes
Yes

Yes

No

No
No

31. Personal characteristics comments

3

SCSEP Participant Form
Certification
I hereby certify that the above information is true and accurate to the best of my
knowledge and belief. I understand that if I intentionally provide inaccurate
information, I may be terminated from the SCSEP program and may be subject to legal
penalties.
32. Signature of applicant
______________________________________
33. Date of signing
_______________________ (MM/DD/YYYY)

4

SCSEP Participant Form
Eligibility Determination
34.

Eligible

Ineligible

35. If ineligible, reason (Check as many as apply)
a. Age
b. Income
c. Residence outside of state
d. Failed to complete application or provide required documentation
e. Other (specify) ________________________________________
36. If ineligible, action taken (Check as many as apply)
a. Referred to One-Stop
b. Referred to social services
c. Referred to another project
d. Placed in unsubsidized employment pursuant to MOU
e. Other (specify) _________________________________________

Enrollment Information
37. Placed on waiting list?

Yes

No

38. Community service assignment?

Yes

No

39. Grantee name __________________________________________________
39a. County of authorized position _____________________________________
40. Co-enrollments? (Check as many as apply)
a. WIOA
b. Employment Service
c. Adult Education
d. College/Community College
e. Other (specify) ____________________________________________________
f. None
40a. Date of orientation _______________________ (MM/DD/YYYY)
40b. Date of last physical or waiver ______________________ (MM/DD/YYYY)
40c. Date of last IEP __________________________ (MM/DD/YYYY)

5

SCSEP Participant Form
40d. Job interest codes: 1________
1. Art, Design, Entertainment,
Sports, and Media
2. Business and Financial
Operations
3. Community and Social Services
4. Computer and Mathematical
5. Construction, Installation, and
Repair
6. Education, Training, and Library
7. Farming, Fishing, and Forestry

2 ________

3________

8. Food Preparation and Service
9. Healthcare
10. Legal
11. Maintenance and Custodial
12. Management
13. Office and Administrative
Support
14. Personal Care and Service

15. Production, Assembly, Light
Industrial
16. Protective Service
17. Retail, Sales, and Related
18. Self-Employment
19. Transportation and Material
Moving

41. Enrollment comments

42. Signature of director or authorized representative
____________________________________________
43. Date of eligibility determination
__________________________(MM/DD/YYYY)

6

SCSEP Participant Form
44. Number in family______

Recertification

45. Total includable family income (12-month or 6-month annualized)
$_____________
Certification
I hereby certify that the above information is true and accurate to the best of my
knowledge and belief. I understand that if I intentionally provide inaccurate
information, I may be terminated from the SCSEP program and may be subject to legal
penalties.
46. Signature of participant on recertification ____________________________
47.

Eligible

Ineligible

48. If ineligible, reason (Check as many as apply)
a. Income
b. Failed to complete application or provide required documentation
c. Other (specify) ________________________________________
49. Signature of director or authorized representative on recertification
______________________________________
50. Date of recertification determination ______________________ (MM/DD/YYYY)

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SCSEP Participant Form
Waiver of Durational Limit
51. Severe disability?
Yes
No
51a. Date of last update ______________________ (MM/DD/YYYY)
52. Frail?
Yes
No
52a. Date of last update ______________________ (MM/DD/YYYY)
53. Old enough for but not receiving SS Title II?
Yes
53a. Date of last update ______________________ (MM/DD/YYYY)

No

54. Severely limited employment prospects in area of persistent unemployment?
Yes
No
54a. Date of last update ______________________ (MM/DD/YYYY)
55. Limited English Proficiency (LEP)?
Yes No
55a. Date of last update ______________________ (MM/DD/YYYY)
56. Low literacy skills?
Yes
No
56a. Date of last update ______________________ (MM/DD/YYYY)
*57. 75 or over?

Yes

No

58. Formerly incarcerated?
Yes
No
58a. Date of last update ______________________ (MM/DD/YYYY)
59. Recertification/waiver comments

*No data entry in SPARQ. Field is system-generated.

8

SCSEP Community Service
Assignment Form

OMB Control Number: 1205-0040
Expiration Date: 11/30/2021

1. Name of participant _______________________ 2. PID _______________________
3. Grantee _______________________________________________________________
Host Agency Information
4. Name of host agency ____________________________________________________
5. Host agency mailing address
_____________________________________________________________________
a. Number and Street, Suite Number; or PO Box

_____________________________________________________________________
b. City

_____________________________________________________________________
c. State

d. ZIP code

6. FEIN ___________________________________
7. Host agency type:

Not-for-profit

Government

7a. Date of host agency agreement _______________________ (MM/DD/YYYY)
7b. Date of host agency monitoring visit _______________________ (MM/DD/YYYY)
8. Host agency site name and location _________________________________________
8a. Host agency job codes: i ________
1. Art, Design, Entertainment,
Sports, and Media
2. Business and Financial
Operations
3. Community and Social Services
4. Computer and Mathematical
5. Construction, Installation, and
Repair
6. Education, Training, and Library
7. Farming, Fishing, and Forestry

ii ________

8. Food Preparation and Service
9. Healthcare
10. Legal
11. Maintenance and Custodial
12. Management
13. Office and Administrative
Support
14. Personal Care and Service

iii ________
15. Production, Assembly, Light
Industrial
16. Protective Service
17. Retail, Sales, and Related
18. Self-Employment
19. Transportation and Material
Moving

This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0040. Persons are not
required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this
collection of information required to obtain or retain benefits (PL 109-365 Sec 501-518) is estimated to average six 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 or any other aspect of this collection, including
suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workforce Investment, Room C-4510, 200 Constitution
Avenue, NW, Washington, DC 20210 (PRA Project 1205-0040).

ETA-9121
(Rev. 2/12/2021)
1

SCSEP Community Service Assignment Form

8b. Host agency continued availability

Available

Not available

Contact/Supervisor Information
9. Name of contact person _________________________________________________
10. Contact person’s mailing address if different from number 5
_____________________________________________________________________
a. Organization

_____________________________________________________________________
b. Number and Street, Suite Number; or PO Box
_____________________________________________________________________
c. City

_____________________________________________________________________
d. State

e. ZIP Code

11. Contact person’s title ___________________________________________________
11a. Contact person’s salutation

Mr.

Ms.

Dr.

12. Contact person’s phone number___________________________________________
12a. Contact person’s fax number ____________________________________________
12a1. Contact person’s cell phone number ______________________________________
12b. Contact person’s e-mail address __________________________________________
Complete fields 12c-12i if supervisor is different from contact person (number 9). If
supervisor is the same as contact person, skip to field 12j.
12c. Name of supervisor ____________________________________________________
12d. Supervisor’s mailing address if different from number 5
_____________________________________________________________________
a. Organization

_____________________________________________________________________
b. Number and Street, Suite Number; or PO Box
_____________________________________________________________________
c. City

_____________________________________________________________________
d. State

e. ZIP Code

12e. Supervisor’s title ______________________________________________________
2

SCSEP Community Service Assignment Form
12f. Supervisor’s salutation

Mr.

Ms.

Dr.

12g. Supervisor’s phone number _____________________________________________
12h. Supervisor’s fax number ________________________________________________
12h1. Supervisor’s cell phone number _________________________________________
12i. Supervisor’s e-mail address ______________________________________________
12j. Funding source of supervisor or contact person/supervisor:
Federal
Non-federal $_______ (hourly rate) _______ (average hours per
week)
Assignment Information
13. Assignment date _______________________________ (MM/DD/YYYY)
14. Start assignment date ___________________________ (MM/DD/YYYY)
15. End date _____________________________________ (MM/DD/YYYY)
15a. Approved break in participation
Start date _________ (MM/DD/YYYY) Expected end date________ (MM/DD/YYYY)
Actual end date__________ (MM/DD/YYYY)
15b. Reason for approved break in participation
i. Family/health
ii. Personal

iii. Administrative
iv. Other (specify)________________

15c. Comments on approved break in participation

16. Participant assigned to:
i. Grantee or sub-recipient/local project
ii. Workforce partner
iii. Other host agency
16a. If participant assigned to i or ii:
1. CSA wage (per hour) $ _______________________
2. Number of hours per week assigned ____________
16b. Participant’s schedule
3

SCSEP Community Service Assignment Form
16c. Date of safety consultation with participant ________________ (MM/DD/YYYY)
17. Community service assignment code_______________(Select only one code from
following lists)
Service to the general community includes the following activities:
G1. Education
G6. Environmental Quality
G2. Health and Hospitals
G7. Public Works & Transportation
G3. Housing and Home Rehabilitation
G8. Social Services
G4. Employment Assistance
G9. Legal
G5. Recreation, Parks, and Forests
G10. Financial
Service to the elderly community includes the following activities:
E1. Project Administration
E6. Nutrition Programs
E2. Health and Home Care
E7. Transportation
E3. Housing and Home Rehabilitation
E8. Outreach/Referral
E4. Employment Assistance
E9. Legal
E5. Recreation/Senior Centers
E10. Financial

G11.
G12.
G13.
G14.

Counseling
Conservation
Community Betterment
Other_______________

E11. Counseling
E12. Conservation
E13. Community Betterment
E14. Other_______________
________________________

18. Community service assignment title _______________________________________
18a. Participant’s job code___________
1. Art, Design, Entertainment,
Sports, and Media
2. Business and Financial
Operations
3. Community and Social Services
4. Computer and Mathematical
5. Construction, Installation, and
Repair
6. Education, Training, and Library
7. Farming, Fishing, and Forestry

8. Food Preparation and Service
9. Healthcare
10. Legal
11. Maintenance and Custodial
12. Management
13. Office and Administrative
Support
14. Personal Care and Service

15. Production, Assembly, Light
Industrial
16. Protective Service
17. Retail, Sales, and Related
18. Self-Employment
19. Transportation and Material
Moving

18b. Participant’s workers’ compensation code___________
19. Total hours paid in quarter
Quarter 1 _______________

Quarter 3 ________________

Quarter 2 _______________

Quarter 4 ________________

20. Types of training received (Check all that apply)
a. General training (basic skills)
b. Specialized training (specific job/industry)
c. On-the-job experience (OJE)

d. Other (specify)______________
e. None

4

SCSEP Community Service Assignment Form
20a.1. Type of supportive service provided:
i. Dependent care (child or adult)
ii. Health and medical services
iii. Housing, including temporary shelter
iv. Incidentals such as work shoes, badges,
uniforms, eyeglasses, and tools

v. Needs-related payments, such as
utilities or food
vi. Special job-related or personal
counseling
vii. Transportation
viii. Other (specify)____________
_______________________________

20a.2. Date supportive service provided________________________ (MM/DD/YYYY)
20a.3. Supportive service provided by:
i. Grantee or sub-recipient/local project
ii. Workforce partner
iii. Both i and ii
iv. Other (specify)________________
21. Total hours of paid training received in quarter
Quarter 1 _______________

Quarter 3 ________________

Quarter 2 _______________

Quarter 4 ________________

21a. Total hours of paid sick leave in quarter
Quarter 1 _______________

Quarter 3 ________________

Quarter 2 _______________

Quarter 4 ________________

22. Community service assignment comments

5

SCSEP Community Service Assignment Form
Sub-Grantee Provided Training Information
Training Provider Information
23. Name of training provider or OJE employer_________________________________
24. Training provider or OJE employer mailing address
_____________________________________________________________________
a. Number and Street, Suite Number; or PO Box

_____________________________________________________________________
b. City

_____________________________________________________________________
c. State

d. ZIP code

25. Training provider continued availability

Available

Not available

Contact Person Information
26. Name of training provider or OJE employer contact person ____________________
27. Contact person’s mailing address if different from number 24
_____________________________________________________________________
a. Organization

_____________________________________________________________________
b. Number and Street, Suite Number; or PO Box
_____________________________________________________________________
c. City

_____________________________________________________________________
d. State

e. ZIP Code

28. Contact person’s title ___________________________________________________
29. Contact person’s salutation

Mr.

Ms.

Dr.

30. Contact person’s phone number___________________________________________
31. Contact person’s fax number _____________________________________________
31a. Contact person’s cell phone number _______________________________________
32. Contact person’s e-mail _________________________________________________

6

SCSEP Community Service Assignment Form
Training Information
33. Types of training received (Check only one per training record)
a. General training (basic skills)
b. Specialized training (specific job/industry)
c. On-the-job experience (OJE)

d. Other (specify)_________________

34. Job code for which training is provided, if relevant ___________
1. Art, Design, Entertainment,
Sports, and Media
2. Business and Financial
Operations
3. Community and Social Services
4. Computer and Mathematical
5. Construction, Installation, and
Repair
6. Education, Training, and Library
7. Farming, Fishing, and Forestry

8. Food Preparation and Service
9. Healthcare
10. Legal
11. Maintenance and Custodial
12. Management
13. Office and Administrative
Support
14. Personal Care and Service

15. Production, Assembly, Light
Industrial
16. Protective Service
17. Retail, Sales, and Related
18. Self-Employment
19. Transportation and Material
Moving

35. Participant’s workers’ compensation code in training ___________
36. Start training date ______________________________ (MM/DD/YYYY)
37. End training date ______________________________ (MM/DD/YYYY)
38. Average number of hours of training per week___________
39. Average number of hours of community service per week during training_________
40. If OJE, wages paid by:
Sub-grantee

Employer and reimbursed by sub-grantee at rate of _____%

41. Training wage (per hour) $ ______________________
42. Total wages paid to participant or reimbursed to employer $ __________________
43. Total amount paid to training provider for provision of training (other than
reimbursement to employer) $ ________________
44. Training Comments

7

SCSEP Unsubsidized Employment Form
1. Name of participant___________________

OMB Control Number: 1205-0040
Expiration Date: 11/30/2021

2. PID __________________________

Employer Information
3. Name of employer ______________________________________________________
4. Employer mailing address
_____________________________________________________________________
a. Number and street, suite number; and/or PO Box

_____________________________________________________________________
b. City

_____________________________________________________________________
c. State

d. ZIP code

5. FEIN_____________________________
6. Employer type
Not-for-profit
Government
7. Is employer a host agency?

For-profit
Self-employment
Yes

No

8. Did employer provide an OJE training site for this participant?

Yes

No

9. Employment site name and location________________________________________
9a. * Date for next customer satisfaction survey for this employer _________
9b. Employer continued availability

Available

Not available

*No data entry in SPARQ. Field is system-generated.

This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0040. Persons are not
required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this
collection of information required to obtain or retain benefits (PL 109-365 Sec 501-518) is estimated to average six 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 or any other aspect of this
collection, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workforce Investment, Room
C-4510, 200 Constitution Avenue, NW, Washington, DC 20210 (PRA Project 1205-0040).

ETA-9122
(Rev. 2/12/2021)
1

SCSEP Unsubsidized Employment Form
Contact/Supervisor Information
10. Name of contact person _________________________________________________
11. Contact person’s mailing address if different from number 4
__________________________________________________________________________________
a. Organization name
__________________________________________________________________________________
b. Number and Street, Suite Number; and/or PO Box
__________________________________________________________________________________
c. City
__________________________________________________________________________________
d. State
e. ZIP Code

12. Contact person’s title ___________________________________________________
12a. Contact person’s salutation

Mr.

Ms.

Dr.

13. Contact person’s phone number___________________________________________
13a. Contact person’s fax number ____________________________________________
13a1. Contact person’s cell phone number ______________________________________
13b. Contact person’s email address ___________________________________________
Complete fields 13c-13i if supervisor is different from contact person (number 10).
If supervisor is the same as contact person, skip to field 14.
13c. Name of supervisor ____________________________________________________
13d. Supervisor’s mailing address if different from number 4
_____________________________________________________________________
a. Organization name

_____________________________________________________________________
b. Number and Street, Suite Number; or PO Box
_____________________________________________________________________
c. City

_____________________________________________________________________
d. State

e. Zip Code

13e. Supervisor’s title ______________________________________________________
13f. Supervisor’s salutation

Mr.

Ms.

Dr.

13g. Supervisor’s phone number _____________________________________________
13h. Supervisor’s fax number ________________________________________________
2

SCSEP Unsubsidized Employment Form
13h1. Supervisor’s cell phone number _________________________________________
13i. Supervisor’s e-mail address ______________________________________________

Placement Information
14. Start date_______________________(MM/DD/YYYY)
15. End date_______________________(MM/DD/YYYY)
16. Starting wage per hour $_____________________
17. Benefits (check all that apply)
a. Health insurance
b. Sick leave
c. Pension/profit
sharing

d. Vacation
e. Transportation
f. Room and
board

g. Other__________(specify)
h. None

18. At time of placement, is employment expected to be full- or part-time?
Full-time

Part-time

If part-time, number of hours per week expected _________
19. Job title ______________________________________________________________
19a. Participant’s job code _________
1. Art, Design, Entertainment,
Sports, and Media
2. Business and Financial
Operations
3. Community and Social Services
4. Computer and Mathematical
5. Construction, Installation, and
Repair
6. Education, Training, and Library
7. Farming, Fishing, and Forestry

19b. High-growth placement
1. Automotive
2. Advanced Manufacturing
3. Biotechnology
4. Construction
5. Energy

8. Food Preparation and Service
9. Healthcare
10. Legal
11. Maintenance and Custodial
12. Management
13. Office and Administrative
Support
14. Personal Care and Service

15. Production, Assembly, Light
Industrial
16. Protective Service
17. Retail, Sales, and Related
18. Self-Employment
19. Transportation and Material
Moving

6. Financial Services
7. Geospatial
8. Health Care
9. Hospitality
10. Information Technology

11. Retail
12. Transportation
13. None

3

SCSEP Unsubsidized Employment Form
20. Training-related placement?

Yes

No

21. Was placement the result of a substantial service provided to the employer by the
sub-grantee?
Yes
No
21a. Type of supportive service provided:
i. Dependent care (child or adult)
ii. Health and medical services
iii. Housing, including temporary shelter
iv. Incidentals such as work shoes, badges,
uniforms, eyeglasses, and tools

v. Needs-related payments, such as
utilities or food
vi. Special job-related or personal
counseling
vii. Transportation
viii. Other (specify)______________
_________________________________

21b. Date supportive service provided________________________ (MM/DD/YYYY)
21c. Supportive service provided by:
i. Grantee or sub-recipient/local project
ii. Workforce partner
iii. Both i and ii
iv. Other (specify)________________
22. Unsubsidized employment comments

Customer Service Survey Information
23. CS survey number 1___________Date of delivery____________ (MM/DD/YYYY)
24. CS survey number 2___________Date of delivery____________ (MM/DD/YYYY)
25. CS survey number 3___________Date of delivery____________ (MM/DD/YYYY)

4

SCSEP Unsubsidized Employment Form
Follow-up Information
26. *90-day date _______________________________ (MM/DD/YYYY)
27. Has the participant returned to program within the first 90 days after exit?
Yes
No
27a. Has the participant re-enrolled in SCSEP within the first 90 days after exit?
Yes
No
28. Follow-up 1
a. *Scheduled date___________________ (MM/DD/YYYY)
b. Completed date ___________________ (MM/DD/YYYY)
c. Any wages for second quarter after exit quarter?
i.
ii.

No wages
Yes, supplemental

29. Follow-up 2
a *Scheduled date___________________ (MM/DD/YYYY)
b Completed date ___________________ (MM/DD/YYYY)
c Earnings for second quarter after exit quarter $_______________
30. Follow-up 3
*Scheduled date___________________ (MM/DD/YYYY)
Completed date ___________________ (MM/DD/YYYY)
Any wages for fourth quarter after exit quarter?
i.
ii.

No wages
Yes, supplemental

31. Customer satisfaction and follow-up comments.

*No data entry in SPARQ. Field is system-generated.

5

SCSEP Exit Form

OMB Approval Number: 1205-0040
Expiration Date: 11/30/2021

Exit Information
1. Name of participant ____________________ 2. PID _____________________________
3. Participant mailing address (if changed)
__________________________________________________________________________
a. Number and Street, Apt. Number; or PO Box

__________________________________________________________________________

b. City

c. County

__________________________________________________________________________
e. ZIP Code

d. State

4. Phone number of participant (if changed) _________________________________________
5. Exit due to unsubsidized placement? (Select one only)
i. Yes, regular employment
ii. Yes, self-employment

iii. No

6.1. If exit is not due to unsubsidized employment, other reason for exit (Select one only)
i. Moved from area
ii. For cause
iii. Voluntary
iv. Durational limit
v. Deceased
vi. Participant’s health/medical
vii. Institutionalized
viii. Reserve personnel called to active duty
ix. Ineligible due to income at recertification
6a. Non-exit reasons for closing the record (Select one only)
i.
Withdrew application prior to assignment
ii.
*Transferred to another project (specify grantee code) __________
iii.
*Moved to another sub-grantee (specify sub-grantee code) __________
iv.
iv. Dual enrollment
6b. Date of termination letter _________________ (MM/DD/YYYY)
7. Date of exit or other closing of record _________________ (MM/DD/YYYY)
*No data entry in SPARQ. Field is system-generated
This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0040. Persons are not required to
respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this collection of
information required to obtain or retain benefits (PL 109-365 Sec 501-518) is estimated to average six (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 or any other aspect of this collection, including suggestions for
reducing this burden, to the U.S. Department of Labor, Office of Workforce Investment, Room C-4510, 200 Constitution Avenue, NW,
Washington, DC 20210 (PRA Project 1205-0040).

ETA-9123
(Rev. 2/12/2021)
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SCSEP Exit Form

Waiver of Confidentiality
I, _________________________________, hereby authorize __________________________________
[name of participant]

[name of employer]

to release to ___________________________________ information regarding my employment status
[name of sub-grantee]

and wages for a period of thirteen months from the date below. This information may be used solely
for statistical purposes and may not be disclosed to anyone not connected with the Senior Community
Service Employment Program (SCSEP) in a manner that is individually identifying.

8.

Signature of participant ___________________________

9.

Date of signing _____________ (MM/DD/YYYY)

9c. Has the participant died since exit?
Yes
No
10. Exit comments

2