ETA 9190 Grants Data Collection Forms

U.S. Department Labor
Employment and Training Administration

OMB Control No. 1205-0219
Expiration Date: 9/30/2022

JOB CORPS GRANTEE DATA COLLECTION: APPLICANT DATA
Program Name:________________________________ Provider:_________________________
Applicant Name:__________________________

_______________________________________________

Applicant ID:______________

SSN:____________________________

Date Application Completed: _________________

Most Recent Date Application Modified: _______________

Last

First

Middle

APPLICANT PRIMARY ADDRESS:
STATE:___________

COUNTY:____________

ZIP CODE:______________

APPLICANT DEMOGRAPHICS:
DOB:___________________

GENDER:  Male

ETHNICITY:

 Not Hispanic/Latino

 Hispanic/Latino

RACE: (select all that apply)

 Female

 Did not self-identify

 American Indian / Alaska Native

 Native Hawaiian / Other Pacific Islander

 Did Not Self-Disclose

 Asian

 White

 Black /African American  Did not self-identify

ACADEMIC AND EMPLOYMENT BACKGROUND AT TIME OF APPLICATION:
HIGHEST SCHOOL GRADE COMPLETED: ___________
HIGHEST EDUCATIONAL LEVEL COMPLETED:  None  HSD  HSE  Certificate of Attendance/Completion of IEP
 Some Post-secondary  AA/AS  Post-secondary Technical/Vocational Certificate  Other:__________________
FILED UNEMPLOYMENT COMPENSATION CLAIM AND IS ELIGIBLE FOR BENEFITS:  YES  NO
Referral by: (select one)  RESEA

 WPRS

 Exhausted Benefits

 Other: __________________________
 Exempt from Work Search Requirements

RECEIVED PUBLIC ASSISTANCE IN LAST SIX MONTHS: (select all that apply)
 Temporary Assistance for Needy Families (TANF)

 SSI  SSDI

 TICKET TO WORK HOLDER

 General Assistance (GA) (State/local government) or Refugee Cash Assistance (RCA)  None
ADDITIONAL YOUTH CHARACTERISTICS AT PROGRAM APPLICATION: (select all that apply)
 Foster Care

 Homeless

 Runaway Youth

 English Language Learner

 Basic Skills Deficient/Low Levels of Literacy

Cultural Barriers:  Yes  No  Did Not Self-Disclose

 Low income Status

Single Parent:  Yes  No  Did Not Self-Disclose

MILITARY EXPERIENCE:
SERVED OR SERVING ON ACTIVE DUTY IN U.S. ARMED FORCES:  YES  NO  DID NOT SELF-DISCLOSE
DATE OF SEPARATION: ____________________
LENGTH OF SERVICE:
 Served 180 days or less on active duty  Served more than 180 days on active duty
Form ETA-9190C

Page 1 of 9

OMB Control No. 1205-0219
Expiration Date: 9/30/2022

SERVICE TYPE:
 Served on active duty during war/campaign/expedition, and  Served as part of a reserve component
DISCHARGE TYPE:  Honorable
 Dishonorable

 Other Than Honorable

 General

 Bad Conduct

 Other:_______________________________

OTHER: (select all that apply)
 Discharged from active duty for a service-connected disability
 Entitled to compensation regardless of rating (including 0%), or entitled but receives military retirement pay,
under laws administered by DVA
 Entitled to compensation, or entitled but receives military retirement pay, under laws administered by DVA
for a disability rated at (i) 30% or more OR (ii) 10% or 20% if determined to have a serious employment handicap
 Homeless veteran
CURRENTLY SERVING IN U.S. ARMED FORCES AND IS WITHIN 12 MONTHS OF SEPARATION OR 24 MONTHS OF
RETIREMENT:  YES  NO
APPLICANT’S SPOUSE SERVED ON ACTIVE DUTY IN U.S. ARMED FORCES:  YES  NO
 Spouse died on active duty or of service-related disability
 Spouse missing in action for 90 or more days at time of application OR Spouse captured in line of duty by
hostile force, or forcibly detained/interned in line of duty by foreign government or power for 90 or more days
at time of application
 Spouse has a total, permanent disability from a service-connected disability or died with such a disability
DISABILITY STATUS:
APPLICANT DISCLOSED A DISABILITY:  YES

 NO  DID NOT SELF-DISCLOSE

DISABILITY TYPE: (select all that apply)  Physical/Chronic Health Condition
 Mental or Psychiatric Disability
 Learning Disability

 Vision-related disability

 Cognitive/Intellectual disability

 Physical/Mobility Impairment

 Hearing-related disability

 Applicant did not disclose type of disability

APPLICANT RECEIVED SERVICES FUNDED BY: (select all that apply)
 SDDA

 LSMHA

 State Medicaid HCBS Waiver

 No Services Funded By These Sources

TYPE OF WORK SETTING: (select all that apply)
 Working in competitive, integrated employment (CIE)

 Working in group supported employment

 Working in a sheltered workshop  Previously employed in supported employment  Not Currently Employed
APPLICANT RECEIVED CUSTOMIZED EMPLOYMENT SERVICES (CES):  YES

 NO

Type of CES: (select one)
 Discovery assessment services
 Developed a customized employment search plan
 Employer negotiation services
 Secured employment as a result of receiving customized employment services and received extended
support services
FINANCIAL CAPABILITY: (select all that apply)
 Received benefit planning services
Form ETA-9190C

 Received financial capability/asset development services  None
Page 2 of 9

OMB Control No. 1205-0219
Expiration Date: 9/30/2022

Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a
currently valid OMB control number and expiration date. Public reporting burden for this collection of information,
which is required to obtain or retain benefits (29 USC 2881), is estimated to average 0.1 hour per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
the completing and reviewing the collection of information. This information collection is for program management
and Congressional reporting purposes. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of
Job Corps. Room N-4507, Washington D.C. 20210 (Paperwork Reduction Project 1205-0219).

Form ETA-9190C

Page 3 of 9

OMB Control No. 1205-0219
Expiration Date: 9/30/2022

U.S. Department Labor
Employment and Training Administration

JOB CORPS GRANTEE DATA COLLECTION: ENROLLEE DATA
Program Name:___________________________________

Provider:_____________________

Applicant Name:_________________________________________________________________________
Last

First

Middle

Applicant ID:______________________________

SSN:____________________________

Date of Enrollment: _________________________

Date of Exit: _________________________

EDUCATION SERVICES RECEIVED:
ENROLLED IN: (select all that apply)

 NONE

 SECONDARY PROGRAM

 POST-SECONDARY PROGRAM

 PROGRAM #1: START DATE: ___________________ DATE CREDENTIAL ATTAINED: ___________________________
CREDENTIAL TYPE:
 HSD
 HSE
 AA/AS
 Other: _________________________
 PROGRAM #2: START DATE: ___________________ DATE CREDENTIAL ATTAINED: ___________________________
CREDENTIAL TYPE:
 HSD
 HSE
 AA/AS
 Other: _________________________
 PROGRAM #3: START DATE: ___________________ DATE CREDENTIAL ATTAINED: ___________________________
CREDENTIAL TYPE:
 HSD
 HSE
 AA/AS
 Other: _________________________
ACADEMIC MILESTONES ACHIEVED:
Date of Most Recent Transcript/Report Card From:
 post-secondary program with 12+ credit hours in a semester (FT) or over 2 semesters (PT) meeting state
unit’s academic standards. Date: ________________
 secondary program meeting state unit’s academic standards. Date: ________________
SCHOLARS GRANTS ONLY: Total Academic Hours Earned since Program Start: ____________
TRAINING SERVICES RECEIVED:
ENTERED TRAINING PROGRAM:

 YES

 NO

 TRAINING # 1: TYPE: ______________________________________________________________
START DATE: ___________________ COMPLETION DATE: ___________________
 TRAINING # 2: TYPE: ______________________________________________________________
START DATE: ___________________ COMPLETION DATE: ___________________
 TRAINING # 3: TYPE: ______________________________________________________________
START DATE: ___________________ COMPLETION DATE: ___________________
TRAINING-RELATED CREDENTIALS ATTAINED:
Record Industry-Recognized Credential or Certification, Certificate of Completion of a Registered Apprenticeship, or a
State or Federal-recognized license attained during program enrollment
 Credential #1: DATE CREDENTIAL ATTAINED: _____________________________
TYPE:  Licensure  Certificate  Certification  Other:________________________
Form ETA-9190B

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OMB Control No. 1205-0219
Expiration Date: 9/30/2022

 Credential #2: DATE CREDENTIAL ATTAINED: _____________________________
TYPE:  Licensure  Certificate  Certification  Other:________________________
 Credential #3: DATE CREDENTIAL ATTAINED: _____________________________
TYPE:  Licensure  Certificate  Certification  Other:________________________
TRAINING MILESTONES ACHIEVED:
 Completed an exam that is required for a particular occupation: MOST RECENT DATE ACHIEVED: _________________
 Progress in attaining technical or occupational skills as evidenced by trade-related benchmarks such as knowledgebased exams. MOST RECENT DATE ACHIEVED: _________________
 A satisfactory or better progress report towards established milestones from an employer/training provider who is
providing training (e.g., completion of on-the-job training (OJT), completion of one year of a registered apprenticeship
program, etc.). MOST RECENT DATE ACHIEVED: _________________
EFL GAINS:
READING:
CATEGORY OF ASSESSMENT:
TEST TYPE:

 ABE

 TABE 11/12

 ESL

 NONE

 CASAS

 OTHER:__________________________________

DATE OF INITIAL TEST: _________________

INITIAL TEST SCORE: ____________

INITIAL TEST EFL____________

DATE OF POST-TEST: _________________

POST-TEST SCORE: ____________

POST-TEST EFL____________

MATH:
CATEGORY OF ASSESSMENT:
TEST TYPE:

 ABE

 TABE 11/12

 ESL

 NONE

 CASAS

 OTHER:_________

DATE OF INITIAL TEST: _________________

INITIAL TEST SCORE: ____________

INITIAL TEST EFL____________

DATE OF POST-TEST: _________________

POST-TEST SCORE: ____________

POST-TEST EFL____________

OTHER:
CATEGORY OF ASSESSMENT:
TEST TYPE:

 TABE 11/12

 ABE

 ESL

 NONE

 CASAS

 OTHER:_________

DATE OF INITIAL TEST: _________________

INITIAL TEST SCORE: ____________

INITIAL TEST EFL____________

DATE OF POST-TEST: _________________

POST-TEST SCORE: ____________

POST-TEST EFL____________

EXIT STATUS:
NON-SCHOLARS GRANTS ONLY:  Graduate

 Former Enrollee

SCHOLARS GRANTS ONLY:  Program Completer

 Other:___________

 Program Non-Completer

EXIT REASON:
 Institutionalized

 Health/Medical

 Foster Care  Ineligible
Form ETA-9190B

 Deceased

 Criminal Offender

 Reserve Forces called to Active Duty

 None of the above
Page 5 of 9

OMB Control No. 1205-0219
Expiration Date: 9/30/2022

Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a
currently valid OMB control number and expiration date. Public reporting burden for this collection of information,
which is required to obtain or retain benefits (29 USC 2881), is estimated to average 0.1 hour per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
the completing and reviewing the collection of information. This information collection is for program management
and Congressional reporting purposes. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of
Job Corps. Room N-4507, Washington D.C. 20210 (Paperwork Reduction Project 1205-0219).

Form ETA-9190B

Page 6 of 9

OMB Control No. 1205-0219
Expiration Date: 9/30/2022

U.S. Department Labor
Employment and Training Administration

JOB CORPS GRANTEE DATA COLLECTION: POST-SEPARATION DATA
Program Name:___________________________________

Provider:_____________________

Applicant Name:_________________________________________________________________________
Last

First

Applicant ID:______________________________

Middle

SSN:____________________________

POST-SEPARATION PLACEMENT:
Qualifying Student Placement (select one):
 One Full Time Job

 Registered Apprentice Full Time Job

 Other Training Program

 Two Full Time Jobs

 Full Time Job/College Combo

 OJT/Paid Employment

 One Part Time Job

 Part Time Job/College Combo

 High School Diploma (HSD) Program

 Two Part Time Jobs

 College

 High School Equivalency (HSE) Program

 Armed Forces

 Post-Secondary School/Training

 Not Placed

Job Training Match:

 YES

 NO

Date First Reported to Placement: _______________

Hourly Wage at Placement: $_______._______

Date Met Placement Hours/Wage/Credit Requirements: _________________________________
Hourly Wage at Six Months After Placement:

SCHOLARS GRANTS ONLY:

$_______._______

Hourly Wage at 12 Months After Placement:$_______._______

FIRST QUARTER AFTER EXIT:
Type of Employment:
 Military

 Registered Apprenticeship

 Other unsubsidized employment

 Not employed

Date First Entered Employment:_________________________________
Date Exited Employment (if applicable):_________________________________
Data Source:
 UI Wage Data

 Federal Employment Records (OPM, USPS)

 Military Employment Records (DOD)

 Non-UI verification
Quarterly Earnings: $__________________________
Post-secondary Enrollment and Degree Attainment:
 Enrolled in Post-Secondary Education/Training

Date Enrolled:_________________________________

 Attained HSD

Date Attained:_________________________________

Form ETA-9190A

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OMB Control No. 1205-0219
Expiration Date: 9/30/2022

 Attained HSE

Date Attained:_________________________________

 Attained AA/AS

Date Attained:_________________________________

SECOND QUARTER AFTER EXIT:
Type of Employment:
 Military

 Registered Apprenticeship

 Other unsubsidized employment

 Not employed

Date First Entered Employment:_________________________________
Date Exited Employment (if applicable):_________________________________
Data Source:
 UI Wage Data

 Federal Employment Records (OPM, USPS)

 Military Employment Records (DOD)

 Non-UI verification
Quarterly Earnings: $__________________________
Type of Education/Training program:
 None

 Occupational Skills Training  Postsecondary Education

 Secondary Education

Start Date of Education/Training program:_________________________________
Post-secondary Enrollment and Degree Attainment:
 Enrolled in Post-Secondary Education/Training

Date Enrolled:_________________________________

 Attained HSD

Date Attained:_________________________________

 Attained HSE

Date Attained:_________________________________

 Attained AA/AS

Date Attained:_________________________________

THIRD QUARTER AFTER EXIT:
Type of Employment:
 Military

 Registered Apprenticeship

 Other unsubsidized employment

 Not employed

Date First Entered Employment:_________________________________
Date Exited Employment (if applicable):_________________________________
Data Source:
 UI Wage Data

 Federal Employment Records (OPM, USPS)

 Military Employment Records (DOD)

 Non-UI verification
Quarterly Earnings: $__________________________
Post-secondary Enrollment and Degree Attainment:
 Enrolled in Post-Secondary Education/Training

Date Enrolled:_________________________________

 Attained HSD

Date Attained:_________________________________

 Attained HSE

Date Attained:_________________________________

Form ETA-9190A

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OMB Control No. 1205-0219
Expiration Date: 9/30/2022

 Attained AA/AS

Date Attained:_________________________________

FOURTH QUARTER AFTER EXIT:
Type of Employment:
 Military

 Registered Apprenticeship

 Other unsubsidized employment

 Not employed

Date First Entered Employment:_________________________________
Date Exited Employment (if applicable):_________________________________
Data Source:
 UI Wage Data

 Federal Employment Records (OPM, USPS)

 Military Employment Records (DOD)

 Non-UI verification
Quarterly Earnings: $__________________________
Type of Education/Training program:
 None

 Occupational Skills Training  Postsecondary Education

 Secondary Education

Start Date of Education/Training program:_________________________________
Employed by Same Employer in Q2 and Q4:  YES

 NO

Post-secondary Enrollment and Degree Attainment:
 Enrolled in Post-Secondary Education/Training

Date Enrolled:_________________________________

 Attained HSD

Date Attained:_________________________________

 Attained HSE

Date Attained:_________________________________

 Attained AA/AS

Date Attained:_________________________________

Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a
currently valid OMB control number and expiration date. Public reporting burden for this collection of information,
which is required to obtain or retain benefits (29 USC 2881), is estimated to average 0.1 hour per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
the completing and reviewing the collection of information. This information collection is for program management
and Congressional reporting purposes. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of
Job Corps. Room N-4507, Washington D.C. 20210 (Paperwork Reduction Project 1205-0219).
Form ETA-9190A

Page 9 of 9