ETA 9191 GPMS Data Collection Instrument

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Overview

Cover
All Data Elements
Job and Exit Codes
Reservations, Tribal Affil
Education and Training

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Sheet 1: Cover

Office of National Programs
Senior Community Service Employment Program
PRA Document for the GPMS
REVISION HISTORY
Revised	Author(s)	Organization
2/18/2021	Katherine Campbell	Mathematica
3/15/2021	Katherine Campbell	Mathematica
7/30/2021	Katherine Campbell	Mathematica

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Sheet 2: All Data Elements

GPMS SCREEN

DATA ELEMENT NAME

DATA TYPE/ FIELD LENGTH

DATA ELEMENT DEFINITIONS/INSTRUCTIONS

CODE VALUE

PIRL #

9120's

Comments

In the GPMS?

PIRL/9120 Duplicate

Substantively the same as approved PIRL item

Requires PRA Approval

Material/Non-Material Change

Manage Sub-Grantee

Sub-Grantee Name

AN 255

Record the Sub-Grantee Name.

Text Field, 255 characters

N

X

Material

Manage Sub-Grantee

Grant Number

AN 14

Record the Grant Number.

Text Field, 14 characters

N

X

Material

Manage Sub-Grantee

Sub-Grantee Code

AN 255

Record the Sub-Grantee Code.

Text Field, 255 characters

N

X

Material

Manage Sub-Grantee

Location

AN 255

Record the Sub-Grantee location.

Text Field, 255 characters

N

X

Material

Manage Sub-Grantee

Comments

AN 2000

Record any Sub-Grantee comments.

Text Field, 2000 characters

N

X

Material

Manage Sub-Grantee

Date First Active

DT 8

Record the date first active for the Sub-Grantee.

YYYYMMDD

N

X

Material

Manage Sub-Grantee

Date Last Active

DT 8

Record the date last active for the Sub-Grantee.

YYYYMMDD

N

X

Material

Manage Organizations

Organization Name

AN 255

Record Host Agency Organization Name

Text Field, 255 characters

9121

Y

X

Non-material

Manage Organizations

FEIN

IN 9

Record FEIN number

000000000

9121

Y

Manage Organizations

Type

Multi Select

Record Organization Type

Host Agency Employer Service Provider

Categorical element, no approval required

Y

Manage Organizations

Organization Type

IN 1

Record Agency Type

Not-for-profit Government Profit

9121

Y

X

Non-material

Manage Organizations

Organization Continued Availability

IN 1

Record 1 for active if organization agency wishes to continue to participate in the program or if grantee/sub-grantee wishes to continue working with this organization agency Record 2 for inactive if organization agency no longer wishes to continue to participate in the program or if grantee/sub-grantee no longer wishes to continue working with the organization agency

Available Not Available

9121

Y

X

Non-material

Manage Organizations

Site Name and Location

AN 255

Record the host agency's site name and location

Text Field, 255 characters

9121

Y

X

Non-material

Manage Organizations

Organization Agreement Date

DT 8

Record Organization Agreement Date

YYYYMMDD

9121

Y

X

Non-material

Manage Organizations

Organization Monitoring Visit Date

DT 8

Record Organization Monitoring Visit Date

YYYYMMDD

9121

Y

X

Non-material

Manage Organizations

Job Codes

Dropdown

Record up to three job codes offered by the Agency

Management Occupations Business and Financial Operations Occupations Computer and Mathematical Occupations Architecture and Engineering Occupations Life, Physical, and Social Science Occupations Community and Social Service Occupations Legal Occupations Educational Instruction and Library Occupations Arts, Design, Entertainment, Sports, and Media Occupations Healthcare Practitioners and Technical Occupations Healthcare Support Occupations Protective Service Occupations Food Preparation and Serving Related Occupations Building and Grounds Cleaning and Maintenance Occupations Personal Care and Service Occupations Sales and Related Occupations Office and Administrative Support Occupations Farming, Fishing, and Forestry Occupations Construction and Extraction Occupations Installation, Maintenance, and Repair Occupations Production Occupations Transportation and Material Moving Occupations Military Specific Occupations Self Employment

9121

See Job and Exit Codes tab

Y

X

Non-material

Manage Organizations

Address Line 1

AN 255

Record the Host Agency Organization Address 1

Text Field, 255 characters

9121

Y

Manage Organizations

Address Line 2

AN 255

Record the Host Agency Organization Address 2

Text Field, 255 characters

9121

Y

Manage Organizations

City

AN 255

Record the Host Agency Organization City

Text Field, 255 characters

9121

Y

Manage Organizations

State

Dropdown

Record the Host Agency Organization State

Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

9121

Y

Manage Organizations

Zip

IN 5

Record the Host Agency Organization Zip

00000

9121

Y

Manage Organizations

Zip + 4

IN 4

Record the Host Agency Organization Zip + 4

0000

Y

X

Material

Manage Organizations

Contact First Name

AN 255

Record host agency contact person's first name

Text Field, 255 characters

9121

Y

Manage Organizations

Contact Last Name

AN 255

Record host agency contact person's last name

Text Field, 255 characters

9121

Y

Manage Organizations

Title

AN 255

Record the host agency contact person's title

Text Field, 255 characters

9121

Y

Manage Organizations

Cell Phone Number

IN 10

Record the host agency contact person's cell phone number

000000000

9121

Y

Manage Organizations

Fax Number

IN 10

Record the host agency contact person's fax number

000000000

9121

Y

Manage Organizations

E-mail

AN 26

Record the host agency contact person's email address

Text Field, 255 characters

9121

Y

Manage Organizations

Address Line 1

AN 255

Record the host agency organization contact person's Address 1 if different from host agency address

Text Field, 255 characters

9121

N

Manage Organizations

Address Line 2

AN 255

Record the host agency organization contact person's Address 2 if different from host agency address

Text Field, 255 characters

9121

N

Manage Organizations

City

AN 255

Record the host agency organization contact person's City if different than host agency address

Text Field, 255 characters

9121

N

Manage Organizations

State

Dropdown

Record the host agency organization contact person's State if different than host agency address

Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

9121

N

Manage Organizations

Zip

IN 5

Record the host agency organization contact person's Zip if different than host agency address

00000

9121

N

Manage Organizations

County

Dropdown

Record the host agency organization contact person's County if different than host agency address

Counties displayed dependent on host agency contact state selection

9121

N

Manage Organizations

Host Agency Supervisor's Organization

AN 255

Record the host agency supervisor's organization

Text Field, 255 characters

9121

N

Manage Organizations

Address Line 1

AN 255

Record the Host Agency Host Agency supervisor's Address 1

Text Field, 255 characters

9121

N

Manage Organizations

Address Line 2

AN 255

Record the Host Agency supervisor's Address 2

Text Field, 255 characters

9121

N

Manage Organizations

City

AN 255

Record the Host Agency supervisor's City

Text Field, 255 characters

9121

N

Manage Organizations

State

Dropdown

Record the Host Agency supervisor's State

Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

9121

N

Manage Organizations

Zip

IN 5

Record the Host Agency supervisor's Zip

00000

9121

N

Manage Organizations

County

Dropdown

Record the Host Agency supervisor's County

Counties displayed dependent on host agency state selection

9121

N

Manage Organizations

Title

AN 255

Record the host agency supervisor's title

Text Field, 255 characters

9121

N

Manage Organizations

Supervisor's Salutation

AN 1

Record the host agency Supervisor's salutation

1= Mr. 2= Ms. 3= Dr.

9121

N

Manage Organizations

Phone number

IN 10

Record the host agency Supervisor's phone number

000000000

9121

N

Manage Organizations

Fax number

IN 10

Record the host agency Supervisor's fax number

000000000

9121

N

Manage Organizations

Cell phone number

IN 10

Record the host agency Supervisor's cell phone number

000000000

9121

N

Manage Organizations

E-mail

AN 255

Record the host agency Supervisor's email address

Text Field, 255 characters

9121

N

Characteristics

Veteran Status

IN 1

Record 1 if the participant is a person who served on active duty in the armed forces and who was discharged or released from such service under conditions other than dishonorable. Record 0 if the participant does not meet the condition described above. Record 9 if participant does not disclose veteran status.

1 = Yes 0 = No 9 =Status not known

300

9120

Y

X

X

Characteristics

Eligible Veteran Status

IN 1

Record 1 if the participant is a person who served in the active U.S. military, naval, or air service for a period of less than or equal to 180 days, and who was discharged or released from such service under conditions other than dishonorable. Record 2 if the participant served on active duty for a period of more than 180 days and was discharged or released with other than a dishonorable discharge; or was discharged or released because of a service connected disability; or as a member of a reserve component under an order to active duty pursuant to section 167(a), (d), or (g), 673 (a) of Title 10, U.S.C., served on active duty during a period of war or in a campaign or expedition for which a campaign badge is authorized and was discharged or released from such duty with other than a dishonorable discharge. Record 3 if the participant is: (a) the spouse of any person who died on active duty or of a service connected disability, (b) the spouse of any member of the Armed Forces serving on active duty who at the time of application for assistance under this part, is listed, pursuant to 38 U.S.C 101 and the regulations issued there under, by the Secretary concerned, in one or more of the following categories and has been so listed for more than 90 days: (i) missing in action; (ii) captured in the line of duty by a hostile force; or (iii) forcibly detained or interned in the line of duty by a foreign government or power; or (c) the spouse of any person who has a total disability permanent in nature resulting from a service connected disability or the spouse of a veteran who died while a disability so evaluated was in existence. Record 0 if the participant does not meet any one of the conditions described above. Leave “blank” if the data is not available.

1 = Yes <=180 days. 2 = Yes, Eligible Veteran 3 = Yes, Other Eligible Person 0 = No

301

9120

Y

X

X

Characteristics

Veteran, Post-9/11 Era

IN 1

Record 1 if participant is a post-9/11 era veteran. Record 0 if the participant is not a post-9/11 era veteran.

1 = Yes 0 = No

2803

9120

Y

X

X

Characteristics

Individual with a Disability

IN 1

Record 1 if the participant indicates that he/she has any "disability”, SCSEP defines “disability” as: a condition attributable to mental or physical impairment, or a combination of mental and physical impairments, that results in substantial functional limitations in one or more of the following areas of major life activity: (A) self-care; (B) receptive and expressive language; (C) learning; (D) mobility; (E) self-direction; (F) capacity for independent living; (G) economic self-sufficiency; (H) cognitive functioning; and (I) emotional adjustment. Record 0 if the participant indicates that he/she does not have a disability that meets the definition. Record 9 if the participant did not self-identify.

1 = Yes 0 = No 9 = Participant did not self-identify

202

9120

Y

X

X

X

Non-material

Characteristics

Disability Reported As

IN 1

Record whether the disability is self reported, or has documentation.

Self Reported Is Documented

9120

Add to PIRL item

Y

X

Non-material

Characteristics

Has the individual received services funded by the State Development Disabilities Agency(SDDA)?

IN 1

For those participants where Individual With A Disability (WIOA) = 1 : Record 1 if the participant has received services funded by the State Developmental Disabilities Agency (SDDA). Record 0 if the participant does not meet any of the conditions described above. Leave blank if this data element does not apply to this participant.

1 = SDDA 0 = No

204

Y

X

X

Non-material

Characteristics

Homeless

IN 1

Record 1 if the participant, at program entry: (1) lacks a fixed, regular, and adequate nighttime residence; and (2) has a primary nighttime residence that is: (i) A supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill); (ii) An institution that provides a temporary residence for individuals intended to be institutionalized; or (iii) A public or private place not designed for, or ordinarily used as, regular sleeping accommodations for human beings. (42 U.S.C. 11302(a)). Record 0 if the participant does not meet the conditions described above.

Yes No

9120

Y

X

Non-material

Characteristics

Failed to Find Employment After Receiving WIOA Title I?

IN 1

Record 1 if the participant was enrolled in WIOA Title I (adult services) prior to enrolling in SCSEP and was unable to obtain employment before enrolling in SCSEP. Record 0 if the participant does not meet conditions above.

1 = Yes 0 = No

2805

9120

Y

X

X

X

Non-material

Characteristics

Primary Language

IN 2

Specify primary language

Amharic Arabic Armenian Bosnian Burmese Cantonese (Yue) Cebuano Chamorro French French Creole German Greek Gujarathi Hebrew Hindi Miao (Hmong) Ilocano Indonesian Italian Hungarian Japanese Korean Laotian Mandarin Malay Marathi (Indian) Mon-Khmer (Cambodian) Navajo Nepali Pakistani Persian (including Dari) Polish Portuguese Punjabi Russian Samoan Serbo-Croatian Somali Spanish Swahili Tagalog Taishan Thai Tongan Urdu Vietnamese Yiddish Other

9120

Y

X

Non-material

Characteristics

Please, Specify Other

AN 255

Specify the Other Primary Language

Text Field, 255 characters

9120

Y

Characteristics

At Risk of Homelessness

IN 1

An individual is at risk for homelessness when the individual lacks the resources and support networks needed to obtain housing. The risk must be real and imminent. In some sense, anyone living below the poverty level may be at risk of homelessness. Being at risk for homelessness is considered along with actual homelessness as a single priority for service and a single factor for the most-in-need measure. An individual may be either at risk for homelessness or homeless, but not both at once. Record 1 if the participant is at risk for homelessness. Record 0 is the participant is not at risk for homelessness.

1 = Yes 0 = No

2804

9120

Y

X

X

X

Non-material

Characteristics

Urban or Rural

IN 1

Record 1 if participant resides in an urban location. “Rural” means an area not designated as a metropolitan statistical area by the Census Bureau; segments within metropolitan counties identified by codes 4 through 10 in the Rural Urban Commuting Area (RUCA) system; and RUCA codes 2 and 3 for census tracts that are larger than 400 square miles and have population density of less than 30 people per square mile. Record 2 if participant resides in a rural location.

1 = Urban 2 = Rural

2800

9120

Y

X

X

X

Non-material

Characteristics

Low Literacy Skills

IN 1

An individual is at risk for homelessness when the individual lacks the resources and support networks needed to obtain housing. The risk must be real and imminent. In some sense, anyone living below the poverty level may be at risk of homelessness. Being at risk for homelessness is considered along with actual homelessness as a single priority for service and a single factor for the most-in-need measure. An individual may be either at risk for homelessness or homeless, but not both at once. Record 1 if the participant is at risk for homelessness. Record 0 is the participant is not at risk for homelessness.

1 = Yes 0 = No

2820

9120

Y

X

X

Characteristics

Low Employment Prospects

IN 1

Low employment prospects means it is likely that an individual will not obtain employment without the assistance of SCSEP or another workforce development program. Persons with low employment prospects have a significant barrier to employment. Significant barriers to employment may include, but are not limited to: lacking a substantial employment history, basic skills, and/or English language proficiency; lacking a high school diploma or the equivalent; having a disability; being homeless; or residing in socially and economically isolated rural or urban areas where employment opportunities are limited. Record 1 if the participant’s employment prospects are low. Record 0 if the participant does not meet the conditions above.

1 = Yes 0 = No

2806

9120

Y

X

X

Characteristics

Unemployment Compensation Eligible Status

IN 1

Record 1 if the participant is a person who (a) filed a claim and has been determined eligible for benefit payments under one or more State or Federal Unemployment Compensation (UC) programs and whose benefit year or compensation, by reason of an extended duration period, has not ended and who has not exhausted his/her benefit rights, and (b) was referred based on participation in the Reemployment Services and Eligibility Assessment (RESEA) program. Record 2 if the participant is a person who (a) filed a claim and has been determined eligible for benefit payments under one or more State or Federal Unemployment Compensation (UC) programs and whose benefit year or compensation, by reason of an extended duration period, has not ended and who has not exhausted his/her benefit rights, and (b) was referred to service through the state's Worker Profiling and Reemployment Services (WPRS) system. Record 3 if the participant is a person who meets condition 2 (a) described above, but was not referred to service through the state's WPRS system or the RESEA program. Record 4 if the participant meets condition 2(a), but has exhausted all UC benefit rights for which he/she has been determined eligible, including extended supplemental benefit rights. Record 5 if the participant is claimant who is exempt from normal work search requirements according state law, and does not have to perform work search activities. Record 0 if the participant was neither a UC Claimant nor an Exhaustee. Leave blank if this data element does not apply to the participant.

1 = Claimant Referred by RESEA 2 = Claimant Referred by WPRS 3 = Claimant Not Referred by RESEA or WPRS 4 = Exhaustee 5 = Claimant is Exempt 0 = Neither Claimant nor Exhaustee

401

Y

X

X

Non-material

Characteristics

Receiving Temporary Assistance to Needy Families (TANF)

IN 1

Record 1 if the participant is listed on the welfare grant or has received cash assistance or other support services from the TANF agency in the last six months prior to participation in the program. Record 0 if the participant does not meet the condition described above. Leave blank if this data element does not apply to the participant.

1 = Yes 0 = No

600

9120

These are substantively similar to 9120 items

Y

X

X

X

Non-material

Characteristics

Receiving Supplemental Nutrition Assistance Program (SNAP)

IN 1

Record 1 if the participant is receiving assistance through the Supplemental Nutrition Assistance Program (SNAP) under the Food and Nutrition Act of 2008 (7 USC 2011 et seq.) Record 0 if the participant does not meet the above criteria.

1 = Yes 0 = No

603

9120

These are substantively similar to 9120 items

Y

X

X

X

Non-material

Characteristics

Supplemental Security Income(SSI) / Social Security Disability Insurance (SSDI) Status

IN 1

Record 1 if the participant is receiving or has received SSI under Title XVI of the Social Security Act in the last six months prior to participation in the program. Record 2 if the participant is receiving or has received SSDI benefit payments under Title XIX of the Social Security Act in the last six months prior to participation in the program. Record 3 if the participant is receiving or has received both SSI and SSDI in the last six months prior to participation in the program. Record 4 if the participant is receiving or has received SSI under Title XVI of the Social Security Act in the last six months prior to participation in the program and is a Ticket to Work Program Ticket Holder issued by the Social Security Administration. Record 5 if the participant is receiving or has received SSDI benefit payments under Title XIX of the Social Security Act in the last six months prior to participation in the program and is a Ticket to Work Program Ticket holder issued by the Social Security Administration. Record 6 if the participant is receiving or has received both SSI and SSDI in the last six months prior to participation in the program and is a Ticket to Work Program Ticket holder issued by the Social Security Administration. Record 0 if the participant does not meet any of the conditions described above.

1 = SSI 2 = SSDI 3 = Both SSI and SSDI 4 = SSI and Ticket Holder 5 = SSDI and Ticket Holder 6 = Both SSI and SSDI and A Ticket Holder 0 = No

602

9120

These are substantively similar to 9120 items

Y

X

X

X

Non-material

Characteristics

Subsidized Housing

IN 1

Record 1 if the participant receives subsidized housing.

Yes No

9120

These are substantively similar to 9120 items

Y

X

Non-material

Characteristics

State or Local Welfare (General Assistance)

IN 1

Record 1 if the participant receives general assistance (GA) from their state or local government.

Yes No

9120

These are substantively similar to 9120 items

Y

X

X

Non-material

Characteristics

Other Public Assistance Recipient?

IN 1

Record 1 if the participant is a person who is receiving or has received cash assistance or other support services from one of the following sources in the last six months prior to participation in the program: General Assistance (GA) (State/local government), or Refugee Cash Assistance (RCA). Do not include foster child payments. Record 0 if the participant does not meet the above criteria. Leave blank if this data element does not apply to the participant.

1 = Yes 0 = No

604

9120

These are substantively similar to 9120 items

Y

X

X

X

Non-material

Characteristics

Please Specify

AN 255

If applicant is receiving or has received public other public assistance, specify other public assistance recipient

Text Field, 255 characters

9120

Y

X

Non-material

Characteristics

Highest Education Level Completed

Dropdown

Please indicate the highest education level completed by the participant.

No Grade School 1 year of school 2 years of school 3 years of school 4 years of school 5 years of school 6 years of school 7 years of school 8 years of school 9 years of school 10 years of school 11 years of school Completed 12 years of school but no HS diploma HS Diploma GED or Certificate of Equivalency for HS 1 year of college completed 2 years of college completed 3 years of college completed BA/BS or equivalent Education beyond a Bachelor's Degree Master's Degree Doctoral Degree Vocational/Technical Degree Associate's Degree

408

9120

Y

X

X

X

Non-material

Characteristics

Greatest Social Need

IN 1

Record if the participant has a need caused by non-economic factors, which include: physical and mental disabilities; language barriers; and cultural, social, or geographical isolation, including isolation caused by racial or ethnic status, that restricts the ability of an individual to perform normal daily tasks or threatens the capacity of the individual to live independently.

Yes No

Y

X

Material

Characteristics

Other Significant Barrier to Employment

IN 1

Record 1 if the veteran or eligible person has a significant barrier to employment not captured elsewhere. Record 0 if there is no other significant barrier to employment. NOTE: The rationale for this data element is that certain significant barriers to employment are captured in other data elements. For instance, “special disabled” or “disabled veteran” is captured in #303, “homeless veterans” is captured in #308; “recently separated” is captured in #304; “ex-offender” is captured in #801, “no secondary school diploma…” is captured in #408, and “low income” is captured in #802. Leave blank if this data element does not apply to the participant

1 = Yes, Other 0 = No

315

Y

X

Characteristics

Other Barrier

AN 255

Record applicant's other barrier

Text Field, 255 characters

9120

Y

Characteristics

Displaced Homemaker

IN 1

Record 1 if the participant, at program entry, has been providing unpaid services to family members in the home and who: (A)(i) has been dependent on the income of another family member but is no longer supported by that income; or (ii) is the dependent spouse of a member of the Armed Forces on active duty (as defined in section 101(d)(1) of title 10, United States Code) and whose family income is significantly reduced because of a deployment (as defined in section 991(b) of title 10, United States Code, or pursuant to paragraph (4) of such section), a call or order to active duty pursuant to a provision of law referred to in section 101(a)(13)(B) of title 10, United States Code, a permanent change of station, or the service-connected (as defined in section 101(16) of title 38, United States Code) death or disability of the member; and (B) is unemployed or underemployed and is experiencing difficulty in obtaining or upgrading employment. Record 0 if the participant does not meet the conditions described above.

1 = Yes 0 = No

807

9120

Y

X

X

Characteristics

Participant Characteristics Comments

AN 2000

Record Eligibility Characteristics Comments

Text Field, 2000 characters

9120

Y

X

Non-material

Characteristics

Formerly Incarcerated

IN 1

Record if the participant has been formerly incarcerated within the past 5 years of the date of eligibility determination.

Yes No

N

X

Material

Eligibility

Reason for Ineligibility

IN 1

Record the reason for applicant's ineligibility.

Age Income Residence out of state Failed to file complete Application Other

9120

Y

X

Non-Material

Eligibility

Eligibility Determination Date

DT 8

Record the date upon which the participant was determined eligible to participate in the Section 167 program.

YYYYMMDD

2231

9120

Y

X

X

X

Non-material

Eligibility

Did the applicant sign the Applicant Certification?

IN 1

Indicate whether the applicant signed the Applicant Certification.

Yes No

9120

The 9120s include the signature line, which in essence encapsulates this element.

X

Non-Material

Eligibility

The applicant signed the Applicant Certification on

DT 8

Record the Date that the applicant signed the Applicant Certification

YYYYMMDD

9120

Y

X

Non-material

Eligibility

Witnessed By

AN 255

Record signature of director or authorized representative

Text Field, 255 characters

9120

Y

X

Non-Material

Eligibility

Action Taken if Ineligible

IN 1

Select all that applies for action taken for ineligibility

Referred to One-Stop Referred to Social Services Referred to another project Placed in unsubsidized employment pursuant to MOU Other

9120

Y

Eligibility

Other Action

AN 255

Specify other action taken from ineligibility

Text Field, 255 characters

9120

Y

Eligibility

Comment

AN 2000

Record Eligibility Comment

Text Field, 2000 characters

Y

X

Material

Eligibility

Eligibility Verified On

DT 8

Record the date on which eligibility was verified on

YYYYMMDD

9120

Y

Eligibility/Recertification

SCSEP Eligible?

IN 1

Record 1 if the applicant is SCSEP eligible. Record 0 if the applicant is not eligible. Eligibility is determined upon initial enrollment, and recertification.

1 = Yes 0 = No

2807

9120

Y

X

X

X

Non-material

Eligibility/Recertification

Number in Family

IN 2

Record the number of individuals in the applicant’s family. A “family” is defined in TEGL 12-06 as husband, wife, and dependent children; parent or guardian and dependent children; or husband and wife. Count only current family members living together. Do not include deceased spouses or separated spouses who are living separately. In addition, consistent with 20 CFR 641.500, an applicant with a disability may, at the option of the applicant, be treated as a family of one for income eligibility determination purposes. Family of-one status does not extend to other members of the applicant’s family. Number in family is recorded upon initial enrollment, and recertification.

00

2801

9120

Y

X

X

Eligibility/Recertification

Total Includable Family Income

IN 1

Record whether the total includable family income is indicative of the 12-month eligibility determination period or if it is for the 6-months prior to the date of application. Total Includable Family Income is recorded upon initial enrollment, and recertification.

12 month 6 month

9120

Element previously recorded via fillling out either 6-month or 12-month income.

Y

X

Non-material

Eligibility

Total includable family income during the 12-month eligibility determination period

DE 7.2

Please record the total includable income during the 12-month eligibility determination period.

0000000

9120

Y

X

Non-material

Eligibility

Total includable family income during the 6-months prior to date of application (annualized)

DE 7.2

Please record the total includable income (annualized) during the 6-months prior to the date of application.

0000000

9120

Y

X

Non-material

Eligibility/Recertification

Other Reason

AN 255

Indicate other reason for ineligibility. Eligibility is determined upon initial enrollment, and recertification.

Text Field, 255 characters

9120

Y

X

Non-material

Intake

Employment Status

Dropdown

Record 1 if the participant, at program entry, (a) is currently performing any work at all as a paid employee, (b) is currently performing any work at all in his or her own business, profession, or farm, (c) is currently performing any work as an unpaid worker in an enterprise operated by a member of the family, or (d) is one who is not working, but currently has a job or business from which he or she is temporarily absent because of illness, bad weather, vacation, labor-management dispute, or personal reasons, whether or not paid by the employer for time-off, and whether or not seeking another job. Record 0 if the participant, at program entry, is not employed but is seeking employment, makes specific effort to find a job, and is available for work. This data element is collected at intake, and upon initial eligibility determination.

1 = Employed 0 = Unemployed

400

9120

Y

X

X

X

Non-material

Intake

Gender

IN 1

Record 1 if the participant indicates that he is male. Record 2 if the participant indicates that she is female. Record 9 if the participant did not self-identify their sex.

1= Male 2 = Female 9 = Participant did not self-identify

201

9120

Y

X

X

X

Non-Material

Intake

Ethnicity Hispanic / Latino?

IN 1

Record 1 if the participant indicates that he/she is a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture in origin, regardless of race. Record 0 if the participant indicates that he/she does not meet any of these conditions. Record 9 if the participant did not self-identify his/her ethnicity.

1 = Yes 0 = No 9 = Participant did not self-identify

210

9120

Y

X

X

X

Non-Material

Intake

Primary Phone

IN 10

Record Applicant primary phone

0000000000

9120

Y

Intake

Cell?

IN 1

Record if Primary Phone Number is a Cell phone number

1 = Yes

Y

X

Material

Intake

Alternate Phone

IN 10

Record Applicant alternate phone

0000000000

9120

Y

Intake

Cell?

IN 1

Record if Alternate Phone Number is a Cell phone number

1 = Yes

Y

X

Material

Intake

Email

AN 255

Record applicant email address

Text Field, 255 characters

9120

Y

Intake

Did Participant Identify Race?

IN 1

Record 1 if participant identified race Record 2 if participant did not identify race

Yes No

9120

Separate from individual PIRL race fields. Based on the data element definition, this may be mapped to the RACE DNVR field. Data element name should be changed.

Y

X

Non-Material

Intake

American Indian or Alaska Native

IN 1

Record 1 if the participant indicates that he/she is a member of an Indian tribe, band, nation, or other organized group or community, including any Alaska Native village or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688) [43 U.S.C. 1601 et seq.], which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians. Record 0 if the participant indicates that he/she does not meet any of these conditions. Record 9 if the participant did not self-identify his/her race.

1 = Yes 0 = No

211

9120

Y

X

X

Intake

Asian

IN 1

Record 1 if the participant indicates that he/she is a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent (e.g., India, Pakistan, Bangladesh, Sri Lanka, Nepal, Sikkim, and Bhutan). This area includes, for example, Cambodia, China, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Record 0 if the participant indicates that he/she does not meet any of these conditions. Record 9 if the participant did not self-identify his/her race.

1 = Yes 0 = No

212

9120

Y

X

X

Intake

Black / African American

IN 1

Record 1 if the participant indicates that he/she is a person having origins in any of the black racial groups of Africa. Record 0 if the participant indicates that he/she does not meet any of these conditions. Record 9 if the participant did not self-identify his/her race.

1 = Yes 0 = No

213

9120

Y

X

X

Intake

Native Hawaiian or Other Pacific Islander

IN 1

Record 1 if the participant indicates that he/she is a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Record 0 if the participant indicates that he/she does not meet any of these conditions. Record 9 if the participant did not self-identify his/her race.

1 = Yes 0 = No

214

9120

Y

X

X

Intake

White

IN 1

Record 1 if the participant indicates that he/she is a person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Record 0 if the participant indicates that he/she does not meet any of these conditions. Record 9 if the participant did not self-identify his/her race.

1 = Yes 0 = No

215

9120

Y

X

X

Intake

Reservation/Pueblo

Dropdown

Please select the reservation/pueblo for the participant

See Reservations, Tribal Affil tab

N

X

Material

Intake

Tribal Affiliation

Dropdown

Please select the tribal affiliation for the participation

See Reservations, Tribal Affil tab

N

X

Material

Intake

Nationality

Dropdown

Please select the nationality for the participant

Bangladeshi Bhutanese Burmese Cambodian Chinese Fijian Filipino Guamanian or Chamorro Hmong Indian Indonesian Japanese Korean Laotian Malay Mongolian Native Hawaiian Nepalese Pacific Islander Pakistani Samoan Sri Lankan Taiwanese Thai Tongan Vietnamese Other (Specify: ) N/A

N

X

Material

Intake

Address Line 1

AN 255

Record applicant physical address line 1

Text Field, 255 characters

9120

Y

Intake

Address Line 2

AN 255

Record applicant physical address line 2

Text Field, 255 characters

9120

Y

Intake

City

AN 255

Record applicant physical address city

Text Field, 255 characters

9120

Y

Intake

State

Dropdown

Record the state of residence if different from mailing address. Residence is defined as an individual’s primary dwelling place or address as demonstrated by appropriate documentation. A homeless individual is considered a resident of the state in which he or she is applying. Grantees may accept residents of other states if there is an approved multi-state agreement.

Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

101

9120

Y

X

X

X

Non-material

Intake

Zip

IN 5

Record the 5-digit zip code of the state of residence if different from mailing address

00000

103

9120

Y

X

X

Intake

Zip + 4

IN 4

Record applicant Zip+4

0000

9120

Y

Intake

County of Residence

Dropdown

Record the applicant's county of residence for physical address

Counties displayed dependent on physical address state selection

9120

Y

X

Non-material

Intake

Address Line 1

AN 255

If mailing address is different from physical address, record address line 1

Text Field, 255 characters

9120

Mailing Address

Y

Intake

Address Line 2

AN 255

If mailing address is different from physical address, record address line 2

Text Field, 255 characters

9120

Mailing Address

Y

Intake

City

AN 255

If mailing address is different from physical address, record city

Text Field, 255 characters

9120

Mailing Address

Y

Intake

State

Dropdown

If mailing address is different from physical address, record State

Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

9120

Mailing Address

Y

Intake

Zip

IN 5

If mailing address is different from physical address, record zip

00000

9120

Mailing Address

Y

Intake

Zip + 4

IN 4

If mailing address of residence is different from physical mailing address, record zip + 4

0000

Mailing Address

Y

X

Material

Intake

County of Residence

Dropdown

If mailing address is different from physical address, record county

Counties displayed dependent on mailing address state selection

102

9120

Mailing Address

Y

X

X

X

Non-material

Intake

Contact Name

AN 255

If secondary contact information is available, record applicant secondary contact name

Text Field, 255 characters

9120

Y

Intake

Relationship to Participant

AN 255

If secondary contact information is available, record relationship to applicant

Text Field, 255 characters

9120

Y

Intake

Primary Phone

IN 10

If secondary contact information is available, record primary phone

0000000000

9120

Y

Intake

Alternate Phone

IN 10

If secondary contact information is available, record alternate phone

0000000000

9120

Y

Intake

Address Line 1

AN 255

If secondary contact information is available, record address line 1

Text Field, 255 characters

9120

Y

Intake

Address Line 2

AN 255

If secondary contact information is available, record address line 2

Text Field, 255 characters

9120

Y

Intake

City

AN 255

If secondary contact information is available, record city

Text Field, 255 characters

9120

Y

Intake

State

Dropdown

If secondary contact information is available, record state

Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

9120

Y

Intake

Email

AN 255

If secondary contact information is available, record e-mail

Text Field, 255 characters

9120

Y

Intake

Zip

IN 5

If secondary contact information is available, record zip

00000

9120

Y

Intake

Application date

DT 8

Record the date on which the individual first applied for Senior Community Service Employment Program services/benefits under the applicable certification.

YYYYMMDD

2847

9120

Y

X

X

X

Non-material

Add to Waitlist

Confirm that you would like to add this participant into the Waitlist.

IN 1

Indicate whether you would like to add this participant onto the Waitlist.

Yes No

Y

X

Material

Add Assignments

Supervisor's Hourly Wage

DE 3.2

Record supervisor's hourly wage

0

9121

N

Add Assignments

Supervisor's Number of Hours per week

IN 2

Record supervisor's number of hours per week

00

9121

N

Add Assignments

Assignment Date

DT 8

Record assignment date

YYYYMMDD

9121

Y

Add Assignments

Assignment Start Date

DT 8

Record assignment start date

YYYYMMDD

9121

Y

Add Assignments

Assignment End Date

DT 8

Record assignment end date

YYYYMMDD

9121

Y

Add Assignments

CSA Code Type

IN 1

Record the Community Service Assignment Code type.

General Elderly

9121

Y

X

Non-material

Add Assignments

CSA Code

Dropdown

Record community service assignment code

See Job and Exit Codes tab

9121

Y

X

Non-material

Add Assignments

Other [General/Elderly] Community Service Assignment Code

AN 255

Specify other community service assignment code

Text Field, 255 characters

9121

Y

X

Non-material

Add Assignments

CSA Title

AN 255

Record community service assignment title

Text Field, 255 characters

9121

Y

X

Non-material

Add Assignments

Participant's Schedule

AN 2000

Record participant schedule

Text Field

9121

Y

Add Assignments

Job Code

Dropdown

Select Participant Job Code for the assignment.

See Job and Exit Codes tab

9121

See Job and Exit Codes tab

Y

X

Non-material

Add Assignments

Workers' Comp Code at Host Agency

AN 255

Record participant's workers' compensation code

Text Field, 255 characters

9121

Y

X

Non-material

Add Assignments

Safety Consultation Date

DT 8

Record consultation date

YYYYMMDD

9121

Y

Add Assignments

Funding Source Type

IN 1

Record 1 if funding source type is federal Record 2 if funding source type is non-federal

1 = Federal 2 = Non-federal

9121

Y

Add Assignments

Assigned To

IN 1

Record where participant is assigned to for his or her community service assignment.

Grantee or sub-recipient/ local project Workforce Partner Other host agency

9121

Y

X

Non-material

Add Assignments

Starting Wage per hour

DE 8.2

Record the current wage at the community service assignment.

000000.00

2831

9121

solely for participant staff - add to instructions, same applies to hours per week in CSA

Y

X

X

X

Non-material

Add Assignments

Hours per week

IN 2

Record participant's number of hours per week

00

9121

solely for participant staff - add to instructions, same applies to hourly wage in CSA

Y

X

Non-material

Add Assignments

Comments

AN 2000

Record host agency assignment comments

Text Field, 2000 characters

9121

Y

X

Non-material

Add Assignments

Supervisor

Dropdown

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

Supervisor values dependent on Host Agency selection

9121

Y

Add Assignments

Survey Contact

Dropdown

Record the participant available survey contact detail

Survey contact values dependent on Host Agency selection

9121

Y

Add Assignments

Host Agency

Dynamic Text Field

Record host agency

Host Agency values dependent on Grantee selection

9121

Y

Add Break

Approved Break Start Date

DT 8

Record the start date of any approved break in participation, such as a leave of absence without pay.

YYYYMMDD

2826

9121

Y

X

X

X

Non-material

Add Break

Expected End Date

DT 8

Record the Expected Break End Date.

YYYYMMDD

9121

Y

Add Break

Actual End Date

DT 8

Record the end date of any approved break in participation.

YYYYMMDD

2827

9121

Y

X

X

Add Break

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

9121

Y

X

Non-material

Add Break

Reason for Approved Break in Participation

IN 1

Record the reason for the leave of absence or other approved break in participation.

1 = Family/health 2 = Personal 3 = Administrative 4 = Right of Return 5 = Other

2828

9121

Y

X

X

X

Material

Add Break

Other Reason

AN 255

Specify other reason for approved break

Text Field, 255 characters

9121

Y

X

Non-material

Add Break

Comments

AN 2000

Record approved break comment

Text Field, 2000 characters

9121

Y

X

Non-material

Add Exit

Unsubsidized Employment Type

IN 1

Record the Unsubsidized Employment Type.

Regular Employment Self-Employment

9123

X

Non-material

Add Exit

Other Reason for Exit

IN 1

Record the reason that applies at the time of exit.

1 = Moved from area 2 = For cause 3 = Voluntary 5 = Durational limit 10 = Exclusions at Exit

2840

9121

Using 2840 to cover all reasons for exit, including exclusions. 2840 does not include "Exclusions at Exit" value, and we do not need all the existing PIRL values.

Y

X

X

X

Non-material

Add Exit

Exclusion at Exit

Dropdown

Record the Exclusion at Exit

08 = Ineligible at Recertification due to income 01 = Institutionalized 02 = Participant's Health/medical 03 = Deceased 04 = Reserve Forces called to Active Duty

923

Additional code value for 923 : Ineligible at Recertification. Not using all existing code values

Y

X

X

Non-material

Add Exit

Exit Date

DT 8

Record the last date the participant received services that are not self-service, information-only, or follow up services. Record this last date of receipt of services only if there are no future services, that are not self-service, information-only, or follow up services, planned from the program. For Titles I, II and III, record the last date of funded service(s). For Vocational Rehabilitation programs, record the date when the participant's record of service is closed pursuant to 34 CFR 361.43 or 361.56. Leave blank if this data element does not apply to the participant.

YYYYMMDD

9123

Y

X

Non-material

Add Exit

Termination Letter Date

DT 8

Record the termination letter date

YYYYMMDD

9123

Y

Add Exit

Waiver of Confidentiality

IN 1

Record the signature of the participant

I hereby certify that the applicant has signed the Waiver of Confidentiality which authorizes the release of information regarding his/her employment status to the Senior Community Service Employment Program (SCSEP) program. This information may be used solely for statistical purposes and may not be disclosed to anyone not connected with SCSEP in a manner that is individually identifying. I hereby certify that the applicant has NOT signed the Waiver of Confidentiality which would authorize the release of information regarding his/her employment status to the Senior Community Service Employment Program (SCSEP) program.

9123

Y

X

Non-material

Add Exit

Date when the Waiver of Confidentiality was signed

DT 8

Record the date on which the participant signed the exit form

YYYYMMDD

9123

Y

X

Non-material

Add Exit

Exit Comments

AN 2000

Record exit comment

Text Field, 2000 characters

9123

Y

X

Non-material

Manage Paid Hours

Paid CSA (In Person) Q1

IN 3

Record the total number of in person CSA hours for which the participant was paid wages in the 1st quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid CSA (In Person) Q2

IN 3

Record the total number of in person CSA hours for which the participant was paid wages in the 2nd quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid CSA (In Person) Q3

IN 3

Record the total number of in person CSA hours for which the participant was paid wages in the 3rd quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid CSA (In Person) Q4

IN 3

Record the total number of in person CSA hours for which the participant was paid wages in the 4th quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid CSA (Remote) Q1

IN 3

Record the total number of remote CSA hours for which the participant was paid wages in the 1st quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid CSA (Remote) Q2

IN 3

Record the total number of remote CSA hours for which the participant was paid wages in the 2nd quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid CSA (Remote) Q3

IN 3

Record the total number of remote CSA hours for which the participant was paid wages in the 3rd quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid CSA (Remote) Q4

IN 3

Record the total number of remote CSA hours for which the participant was paid wages in the 4th quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid Sick Leave Q1

IN 3

Record the total number of hours of paid sick for which the participant was paid wages in the 1st quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid Sick Leave Q2

IN 3

Record the total number of hours of paid sick for which the participant was paid wages in the 2nd quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid Sick Leave Q3

IN 3

Record the total number of hours of paid sick for which the participant was paid wages in the 3rd quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid Sick Leave Q4

IN 3

Record the total number of hours of paid sick for which the participant was paid wages in the 4th quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Participant Required Actions Activities Q1

IN 3

Record the total number of hours of PRA Activities for which the participant was paid wages in the 1st quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Participant Required Actions Activities Q2

IN 3

Record the total number of hours of PRA Activities for which the participant was paid wages in the 2nd quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Participant Required Actions Activities Q3

IN 3

Record the total number of hours of PRA Activities for which the participant was paid wages in the 3rd quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Participant Required Actions Activities Q4

IN 3

Record the total number of hours of PRA Activities for which the participant was paid wages in the 4th quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid Training (In Person) Q1

IN 3

Record the total number of hours of in person paid training for which the participant was paid wages in the 1st quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid Training (In Person) Q2

IN 3

Record the total number of hours of in person paid training for which the participant was paid wages in the 2nd quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid Training (In Person) Q3

IN 3

Record the total number of hours of in person paid training for which the participant was paid wages in the 3rd quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid Training (In Person) Q4

IN 3

Record the total number of hours of in person paid training for which the participant was paid wages in the 4th quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid Training (Remote) Q1

IN 3

Record the total number of hours of remote paid training for which the participant was paid wages in the 1st quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid Training (Remote) Q2

IN 3

Record the total number of hours of remote paid training for which the participant was paid wages in the 2nd quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid Training (Remote) Q3

IN 3

Record the total number of hours of remote paid training for which the participant was paid wages in the 3rd quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Manage Paid Hours

Paid Training (Remote) Q4

IN 3

Record the total number of hours of remote paid training for which the participant was paid wages in the 4th quarter of the program year as determined from the sub-grantee’s wage records.

000

Y

X

Material

Add Placement

Host Agency Employer?

IN 1

Record 1 if the employer is a host agency. Unsubsidized employers that have served as a host agency for any participant (under any state or national grant) in the last 12 months will not be included in the customer service survey of employers. Record 0 if employer is not a host agency.

1 = Yes 0 = No

2843

9122

Y

X

X

X

Non-material

Add Placement

Did employer provide an OJE training site?

IN 1

Record 1 if employer provided an OJE training Record 0 if employer did not provide OJE

Yes No

9122

Y

X

Non-material

Add Placement

Start Date

DT 8

Record the date on which the participant began work with this employer. This will be the date of placement for measurement purposes.

YYYYMMDD

2845

9122

Y

X

X

Add Placement

End Date

DT 8

Record the date on which the unsubsidized employment with this employer ended. If there is additional unsubsidized employment within four quarters after the quarter of exit from SCSEP, all unsubsidized employment may be included in the performance measures.

YYYYMMDD

2846

9122

Y

X

X

Add Placement

Self Employed?

IN 1

Record whether the participant was self-employed.

Yes No

9122

Y

X

Non-material

Add Placement

Job Title

AN 255

Record the participant job title

Text Field, 255 characters

9122

Y

Add Placement

Job Code

Dropdown

Record job code for the placement.

See Job and Exit Codes tab

9122

See Job and Exit Codes tab

Y

X

Non-material

Add Placement

Training-Related placement?

IN 1

Record 1 if after training program completion, the employment in which the individual entered uses a substantial portion of the skills taught in the training received by the individual. This data element is training program completion based. Individuals that have not enrolled in and completed training should not be reported in this data element. Record 0 if the employment in which the individual entered does not use a substantial portion of the skills taught in the training received by the individual. Record 9 if unknown. Leave blank if the individual has not completed a training program and/or has not yet entered employment

Yes No

9122

Y

X

Non-material

Add Placement

Was Placement result of a Substantial Service Provided to Employer by Sub-Grantee?

IN 1

Record whether the placement was a result of a substantial service provided to employer by sub-grantee.

Yes No

9122

Y

X

Non-material

Add Placement

High-growth Placement

Dropdown

Record which high-growth sector the placement falls under

Automotive Advanced Manufacturing Biotechnology Construction Energy Financial Services Geospatial Health Care Hospitality Information Technology Retail Transportation None

9122

Y

Add Placement

Comments

AN 2000

Record the participant unsubsidized employment comments.

Text Field, 2000 characters

9122

Y

X

Non-material

Add Placement

Starting Wage per hour

DE 8.2

Record the hourly wage at placement. Hourly wage includes any bonuses, tips, gratuities, commissions, and overtime pay earned. Record 00.00 if the participant was not placed into unsubsidized employment. SPECIAL NOTE: Decimal point in entry must be explicit. Leave blank if data element does not apply to the participant.

0000000.00

9122

Y

Add Placement

Type of Placement

IN 1

Record 1 if participant is working full-time at placement. Record 2 if participant is working part-time at placement.

1 = Full-time 2 = Part-time

2822

9122

Y

X

X

Add Placement

Expected Hours per Week

IN 2

Record expected hours per week if participant is working at a part-time placement.

00

2204

9122

Y

X

X

X

Non-material

Add Placement

Benefits

IN 1

Record the benefits the participant received if the participant was placed into unsubsidized employment where the employer makes available (or will make available following the completion of a probationary period) to the participant (whether or not the participant accepts) fringe benefits, beyond those required by law (e.g., Unemployment Insurance, worker’s compensation), including health insurance benefits, holiday or vacation pay, sick leave, or a pension plan (not including social security). Record 0 if the participant was placed into unsubsidized employment where the employer does not make available fringe benefits. Leave blank if data element does not apply to the participant.

Health Insurance Sick Leave Pension / Profit Sharing Vacation Transportation Room and board Other, specify None

9122

Y

X

Non-material

Add Placement

Other Benefits

AN 255

Record any other benefits received during placement

Text Field, 255 characters

Y

X

Material

Add Placement

Customer satisfaction comment

AN 2000

Record customer satisfaction comment

Text Field, 2000 characters

9122

N

X

Non-material

Add Placement

Customer Satisfaction Survey 1 #

IN 5

Record survey #1 number

00000

9122

Y

X

Non-material

Add Placement

Date of delivery

DT 8

Record the date for the first survey delivered to a qualified employer

YYYYMMDD

9122

Y

Add Placement

Customer Satisfaction Survey 2 #

IN 5

Record survey #2 number

00000

9122

Y

X

Non-material

Add Placement

Date of delivery

DT 8

Record the date for the second survey delivered to a qualified employer

YYYYMMDD

9122

Y

Add Placement

Customer Satisfaction Survey 3 #

IN 5

Record survey #3 number

00000

9122

Y

X

Non-material

Add Placement

Date of delivery

DT 8

Record the date for the third survey delivered to a qualified employer

YYYYMMDD

9122

Y

Add Placement

Follow Up 1 Date

DT 8

Record the date of 1st Quarter follow-up

YYYYMMDD

9122

Y

X

Non-material

Add Placement

Any wages for second quarter after exit quarter?

IN 1

Record if there were any wages for second quarter after exit quarter.

Yes No

9122

Y

X

Non-material

Add Placement

Follow Up 1 Notes

AN 2000

Record any notes for follow up 1.

Text Field, 2000 characters

Y

X

Material

Add Placement

Follow Up 2 Date

DT 8

Record the date of 2nd Quarter follow-up

YYYYMMDD

9122

Y

X

Non-material

Add Placement

Earnings for the Second Quarter After the Exit Quarter?

DE 6.2

Record the participant total quarterly earning during 2nd Quarter

000000.00

1704

9122

Y

X

X

X

Non-material

Add Placement

Follow Up 2 Notes

AN 2000

Record any notes for follow up 2.

Text Field, 2000 characters

Y

X

Material

Add Placement

Follow Up 3 Date

DT 8

Record the date on which the 4th Quarter follow-up is conducted

YYYYMMDD

9122

Y

X

Non-material

Add Placement

Any wages for fourth quarter after exit quarter?

IN 1

Record whether there were any wages for fourth quarter after the exit quarter.

Yes No

9122

Y

X

Add Placement

Follow Up 3 Notes

AN 2000

Record any notes for follow up 3.

Text Field, 2000 characters

Y

X

Material

Add Placement

Employed in 2nd Quarter After Exit Quarter (WIOA)

IN 1

Record 1 if the participant is in unsubsidized employment (not including Registered Apprenticeship, or the military). Record 2 if the participant is in a Registered Apprenticeship. Record 3 if the participant is in the military. Record 0 if the participant was not employed in the second quarter after the quarter of exit. Record 9 if the participant has exited but employment information is not yet available.

1 = Yes 2 = Yes, Registered Apprenticeship 3 = Yes, Military 0 = No 9 = Information not yet available

1602

N

X

Add Placement

Employed in 4th Quarter After Exit Quarter (WIOA)

IN 1

Record 1 if the participant is in unsubsidized employment (not including Registered Apprenticeship, or the military). Record 2 if the participant is in a Registered Apprenticeship. Record 3 if the participant is in the military. Record 0 if the participant was not employed in the fourth quarter after the quarter of exit. Record 9 if the participant has exited but employment information is not yet available.

1 = Yes 2 = Yes, Registered Apprenticeship 3 = Yes, Military 0 = No 9 = Information not yet available

1606

N

X

Add Placement

Supervisor

Dropdown

Record supervisor's name for participant's employment only if different than contact

Supervisor values dependent on Employer selection

9122

Y

Add Placement

Employer

Dropdown

Record the participant employer details

Employer values dependent on Grantee selection

9122

Y

Add Placement

Survey Contact

Dropdown

Record the contact person’s name as it should appear on the cover letter and mailing envelope for the customer satisfaction survey

Survey contact values dependent on Employer selection

9122

Y

Add Service

Type

Dropdown

Select type of services

Review Service Tab

9121

Y

Add Service

Other Type

AN 255

Specify other type of service received

See Education and Training values on Services tab

9121

Y

X

Material

Add Service

Sub-Category

Dropdown

Select Referrals type sub-category

See Education and Training values on Services

Y

X

Material

Add Service

Other Sub-Category

AN 255

Specify other type of referral

See Education and Training values on Services

Y

X

Material

Add Service

Sub-Category

Dropdown

Select Education Remediation and Literacy type sub-category

See Education and Training values on Services

Y

X

Material

Add Service

Other Sub-Category

AN 255

Specify other type of Educational Remediation and Literacy received

See Education and Training values on Services tab

Y

X

Material

Add Service

Employment Assistance

AN 255

Specify Employment Assistance received

Text Field, 255 characters

Y

X

Material

Add Service

Persinger, Alex C - OASAM OCIO CTR: Not sure why start date is listed twice? Start Date

DT 8

Record education or training start date

YYYYMMDD

9121

Y

Add Service

Start Date

DT 8

Record service Start Date

YYYYMMDD

9121

Y

Add Service

Expected End Date

DT 8

Record the expected end date for the training or service

YYYYMMDD

9121

Y

Add Service

Actual End Date

DT 8

Record the actual end date for the training or service

YYYYMMDD

9121

Y

X

Non-material

Add Service

Initial Date

DT 8

Record the initial referral date.

YYYYMMDD

Y

X

Material

Add Service

Follow-Up Date

DT 8

Record date to follow up on referral

YYYYMMDD

Y

X

Material

Add Service

Follow-Up Completed

DT 8

Record the Referral Follow-up completed date

YYYYMMDD

Y

X

Material

Add Service

Follow-up Successful

IN 1

Record whether the referral was successful. Leave blank if unknown

Yes No

Y

X

Material

Add Service

Follow-up Outcome

Dropdown

Record the referral follow-up outcome

Referral Service Received Not Completed

Y

X

Material

Add Service

Hourly training wages

DE 8.2

Record the participant’s hourly training wage. Leave blank if the participant was not enrolled in training. This is OJE-specific.

000000.00

2519

9121

Y

X

X

X

Non-material

Add Service

Hours per week

IN 2

Record the average number of hours of training/education per week outside of community service assignment

00

9121

Y

X

Non-material

Add Service

Comments

AN 2000

Record any Training/Services comments

Text Field, 2000 characters

9121

Y

X

Non-material

Add Service

Reason

AN 2000

Record reason for referral

Text Field, 2000 characters

Y

X

Material

Add Service

Supportive Service Provided by

IN 1

Record 1 if participant received supportive services from the grantee or sub-recipient/local project. Record 2 if participant received supportive services from the workforce partner. Record 3 if participant received supportive services from both the grantee or sub-recipient/local project and the workforce partner. Record 4 if participant received supportive services from other sources.

1 = Grantee or sub-recipient/local project 2 = Workforce partner 3 = Other 4 = Both I and ii 5 = Both I and iii

2830

9121

Y

X

X

Add Service

Percentage of supportive services paid by Grantee

DE 6.2

Percentage of supportive services paid by Grantee

000000.00

N

X

Material

Add Service

Specify Other Provider of Supportive Services

AN 255

Specify other provider of supportive services

Text Field, 255 characters

9121

N

Add Service

Training/Service Completed?

IN 1

Record Yes if the participant completed approved training Record No 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

Yes No

9121

N

X

Non-material

Add Service

Job Code for which training is provided, if relevant

Dropdown

Please record the job code for which training is provided, if relevant.

See Job and Exit Codes tab

9121

See Job and Exit Codes tab

N

Add Service

Participant's Workers compensation code in training

AN 255

Record participant's workers' compensation code

Text Field, 255 characters

9121

N

Add Service

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

Sub-grantee Employer Reimbursement by sub-grantee at rate of _____%

9121

N

Add Service

If OJE is Reimbursement, percentage of rate

DE 6.2

Record the percentage of reimbursement rate if OJE is reimbursed

000.00

9121

N

Add Service

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

9121

N

Add Service

Total paid to training provider for provision of training (other than reimbursement to employer)

DE 6.2

Total paid to training provider for provision of training (other than reimbursement to employer)

000000.00

9121

N

Add Service

Provider

Dynamic Text Field

Search available provider in system. In the case of referral for follow-up services, enter name of referral recipient. Add new if the desired provider does not exist.

Provider values dependent upon Grantee selection

9121

Y

X

Non-material

Move

Move Effective Date

DT 8

Record the effective date of move

YYYYMMDD

Y

X

Material

Other enrollment information

Co-enrollment in WIOA Adult Formula program?

IN 1

Record 1 if the participant received services under WIOA section 133(b)(2)(A) as an individual who is not less than age 18 at the time of program entry. Record 2 if the participant received services under WIOA section 133(a)(1). Record 3 if the participant received services under WIOA sections 133(b)(2)(A) and 133(a)(1). Record 4 if the individual has demonstrated an intent to use program services and meets one of the following criteria--- (A) Individuals who provide identifying information; (B) Individuals who only use the self-service system; or (C) Individuals who only receive information-only services or activities. Record 0 if the participant did not receive services under the condition described above.

1 = Yes 0 = No

903

Y

X

X

Non-material

Other enrollment information

Co-enrollment in Title II Adult Education (WIOA)?

IN 1

Record 1 if the participant received services under WIOA Title II defined as academic instruction and education services below the postsecondary level that increases an individual’s ability to--- (A) read, write, and speak in English and perform mathematics or other activities necessary for the attainment of a secondary school diploma or its recognized equivalent; (B) transition to postsecondary education and training; and (C) obtain employment. Record 0 if the participant did not receive any services under the conditions described above. Record 9 if the grantee is unable to track enrollment in the program.

1 = Yes 0 = No 9 = Unknown

910

9120

Y

X

X

X

Non-material

Other enrollment information

Co-enrollment in National Farmworker Jobs Program?

IN 1

Record if the participant received services under WIOA Title I-D, Section 167. Leave blank if the participant did not receive services funded by this program.

Yes No

Y

X

Material

Other enrollment information

Co-enrollment in Indian and Native American Programs?

IN 1

Record 1 if the participant received services under WIOA Title I-D, Section 166 Record 2 if the individual has demonstrated an intent to use program services and meets one of the following criteria--- (A) Individuals who provide identifying information; (B) Individuals who only use the self-service system; or (C) Individuals who only receive information-only services or activities. Leave blank if the participant did not receive services funded by this program.

1 = Yes 2 = Reportable Individual

913

Y

X

X

Non-material

Other enrollment information

Co-enrollment in Veterans' Programs?

IN 2

Record 1 if the participant received services from a Disabled Veterans Outreach Program specialist (DVOP specialist). Record 2 if the participant received services from a Local Veterans Employment Representative (LVER). Record 0 if the participant did not receive services under any of the conditions described above. Record 9 if grantee is unable to track enrollment in the program.

1 = Yes, DVOP specialist 2 = Yes, LVER specialist 0 = No 9 = Unknown

914

Y

X

X

Non-material

Other enrollment information

Co-enrollment in Vocational Education program?

IN 1

Record 1 if the participant received services under the Carl D. Perkins Vocational and Applied Technology Education Act (20 USC 2301 et seq.). Record 0 if the participant did not receive any services under the condition described above. Record 9 if unknown. Leave blank if this data element does not apply to the participant.

1 = Yes 0 = No 9 = Unknown

916

Y

X

X

Non-material

Other enrollment information

Co-Enrollment in WIOA Vocational Rehabilitation program?

IN 1

Record 1 if the participant received services under parts A and B of title I of the Rehabilitation Act of 1973 (29 USC 720 et seq.), WIOA title IV, and Sec. 411(B)(15) defined as transition services for students with disabilities, that facilitate the transition from school to postsecondary life, such as achievement of an employment outcome in competitive integrated employment, or pre-employment transition services. Record 2 if the participant received services from the Vocational Rehabilitation and Employment (VR&E) Program authorized by 38 USC Chapter 31. Record 3 if the participant received services from both vocational rehabilitation programs. Record 0 if the participant did not receive any services under the conditions described above. Record 9 if unknown.

1 = Yes 2 = VR&E 3 = Both VR and VR&E 0 = No 9 = Unknown

917

Y

X

X

Non-material

Other enrollment information

Co-Enrollment in Wagner-Peyser Employment Service program?

IN 1

Record 1 if the participant received services under the Wagner-Peyser Act (29 USC 49 et seq.) Record 2 if the individual has demonstrated an intent to use program services and meets one of the following criteria--- (A) Individuals who provide identifying information; (B) Individuals who only use the self-service system; or (C) Individuals who only receive information-only services or activities. Record 0 if the participant did not receive services under the Wagner-Peyser Act. Record 9 if the grantee is unable to track enrollment in the program.

1 = Yes 2 = Reportable Individual 0 = No 9 = Unknown

918

9120

Y

X

X

X

Non-material

Other enrollment information

Receiving Employment and Training Services Related to SNAP?

IN 1

Record 1 if the participant received employment and training (E&T) services from the Supplemental Nutrition Assistance Program (SNAP) (7 USC 2015(d)(4)) - NOTE: This refers to the SNAP E&T program, NOT simply a SNAP recipient. Record 0 if the participant did not receive any services under the condition described above. Leave blank if it is not known.

1 = Yes 0 = No

921

Y

X

X

Non-material

Other enrollment information

Co-enrollment in Other WIOA or Non-WIOA Programs?

IN 1

Record 1 if the participant received services from any other WIOA or non-WIOA program not listed above that provided the participant with services during their period of participation. Record 2 if the participant received services from the Intellectual and/or Developmental Disability Program, Mental Health Program, or any other Employment First State Leadership Mentoring Program (EFSLMP) during the period of participation. Record 0 if the participant did not receive any services under either of the conditions described above.

1 = Yes, Other WIOA or Non-WIOA Programs 2 = I/DD, MH or other disability programs 0 = No

922

9120

Y

X

X

X

Non-material

Other enrollment information

If Other, Please Specify

AN 255

If participant received services from any other program, please specify.

Text Field, 255 characters

9120

Y

X

Non-material

Other enrollment information

Job Codes

Dropdown

Please record the participant's interest job code.

See Job and Exit Codes tab

9120

See Job and Exit Codes tab

Y

X

Non-material

Other enrollment information

Comments

AN 2000

Record Enrollment Comment

Text Field, 2000 characters

9120

Y

X

Non-material

Participant Details

Social Security Number

IN 9

Record the Social Security Number (SSN) assigned to the participant. NOTE: THE SSN MUST NOT BE INCLUDED UNLESS SPECIFIED UNDER PROGRAM OR FUNDING STREAM REPORTING REQUIREMENTS.

000000000

2700

9120

Y

X

X

Participant Details

First Name

AN 255

Record participant first name

Text Field, 255 characters

9120

Y

Participant Details

Middle Initial

AN 1

Record participant middle initial

Text Field, 255 characters

9120

Y

Participant Details

Last Name

AN 255

Record participant last name

Text Field, 255 characters

9120

Y

Participant Details

Date of Birth

DT 8

Record the participant's date of birth.

YYYYMMDD

200

9120

Y

X

X

Participant Required Actions - Assessment (and Reassessment) of Skill level and other service needs

IEP

DT 8

Record the date on which the participant's Individual Employment Plan (IEP) was created or otherwise established to identify the participant's employment goals, their appropriate achievement objectives, and the appropriate combination of services for the participant to achieve the employment goals. Leave blank if an employment plan was not created for the participant, or if the individual is not a participant.

YYYYMMDD

1202

9120

Y

X

X

X

Non-material

Participant Required Actions - Assessment (and Reassessment) of Skill level and other service needs

Assessment (Re-assessment)

DT 8

Record the most recent date on which the participant received assessment services funded by the program. Leave blank if the participant did not receive Assessment Services.

YYYYMMDD

2103

Y

X

X

Non-material

Participant Required Actions - Assessment (and Reassessment) of Skill level and other service needs

Supportive Services Needed?

IN 1

Record whether the participant needs supportive services.

Yes No

Y

X

Material

Participant Required Actions - Assessment (and Reassessment) of Skill level and other service needs

Provided By

AN 255

Record who provided the supportive service.

Text Field, 255 characters

Y

X

Material

Participant Required Actions - Durational Limit Transition Plan

Date transition plan started

DT 8

Start Date of transition plan.

YYYYMMDD

N

X

Material

Participant Required Actions - Durational Limit Transition Plan

Follow Up Date 1

DT 8

Date of first update on transitional activities.

YYYYMMDD

N

X

Material

Participant Required Actions - Durational Limit Transition Plan

Follow Up Date 2

DT 8

Date of second update on transitional activities.

YYYYMMDD

N

X

Material

Participant Required Actions - Durational Limit Transition Plan

Follow Up Date 3

DT 8

Date of third update on transitional activities.

YYYYMMDD

N

X

Material

Participant Required Actions - Durational Limit Transition Plan

Date plan completed

DT 8

Date plan completed.

YYYYMMDD

N

X

Material

Participant Required Actions - Durational Limit Transition Plan

Elements included in plan

IN 2

Check all that apply.

Economic self-sufficiency Unsubsidized Employment Stable/Affordable housing Access to medical care Access to Transportation Socialization Volunteerism/community engagement Referrals to other Aging and social services programs (e.g. RSVP, foster grand parenting) Benefit counseling Other, Specify:

N

X

Material

Participant Required Actions - Durational Limit Transition Plan

Specify, Other

AN 255

Specify other element included in transition plan.

Text Field, 255 characters

N

X

Material

Participant Required Actions - Evaluation of the Need for Supportive Services

Evaluation of Need for Supportive Services Assessment

DT 8

Record the date of the evaluation of need for supportive services assessment.

YYYYMMDD

N

X

Material

Participant Required Actions - Offer of Physical Exam/Waiver

Date

DT 8

Indicate the date that the participant received a physical exam or chose to waive the physical exam.

YYYYMMDD

9120

Y

X

Non-material

Participant Required Actions - Offer of Physical Exam/Waiver

Participant Waiver?

IN 1

Record whether the participant has a waiver.

Yes No

Y

X

Material

Participant Required Actions - Offer of Physical Exam/Waiver

Provided By

AN 255

Record who provided the offer of physical exam/waiver.

Text Field, 255 characters

Y

X

Material

Participant Required Actions - Orientation

Date

DT 8

Indicate the date that the participant was given employment orientation.

YYYYMMDD

9120

Y

X

Non-material

Participant Required Actions - Orientation

Provided By

AN 255

Record who provided the orientation.

Text Field, 255 characters

Y

X

Material

Program Introduction

Pre-Assessment Date

DT 8

Record the date of Pre-Assessment .

YYYYMMDD

Y

X

Material

Program Introduction

Program Overview Date

DT 8

Record the date of program overview.

YYYYMMDD

Y

X

Material

Recertification

Recertification Date

DT 8

Record the date on which the authorized individual made the eligibility determination at recertification.

YYYYMMDD

9120

Y

X

Non-material

Recertification

Total includable family income during the 12-months prior to date of recertification

DE 7.2

Please record the total includable income during the 12-months prior to date of recertification.

0000000

9120

Y

X

Non-material

Recertification

Total includable family income during the 6-months prior to date of recertification (annualized)

DE 7.2

Please record the total includable income (annualized) during the 6-months prior to the date of recertification.

0000000

9120

Y

X

Non-material

Recertification

Reason for Ineligibility

IN 4

If the applicant is ineligible, record the reason for ineligibility at recertification. Record all that apply. Record 0 if the participant remains eligible at recertification.

1 = Income 2 = Failed to file complete Application or provide required documentation 3 = Other

2808

Y

X

X

Non-material

Recertification

Signature of participant on Recertification?

IN 1

Record if Applicant signed the Applicant Form at recertification.

Yes No

9120

Y

X

Non-material

Recertification

Signature of director or authorized representative on recertification?

IN 1

Record signature of director or authorized representative at recertification.

Yes No

9120

Y

X

Non-material

Recertification

Comment

AN 2000

Record recertification comments.

Text Field, 2000 characters

9120

Y

X

Non-material

Transfer

Requested Effective Date

DT 8

Record the effective date of transfer.

YYYYMMDD

9123

Y

X

Non-material

Transfer

Transfer Initiator

IN 1

Record who initiated the transfer.

Grantee Participant

Y

X

Material

Transfer

Reason For Transfer

Dropdown

Record the reason for getting transfer.

Result of approved swap of authorized positions Participant was orphaned Other administrative reasons Participant is moving Other

9123

Y

X

Non-material

Transfer

Please, Specify Other

AN 255

Specify other reason for transfer.

Text Field, 255 characters

Y

X

Material

Transfer

Address Line 1

AN 255

Record Physical Address Line 1 After Transfer.

Text Field, 255 characters

Y

X

Material

Transfer

Address Line 2

AN 255

Record Physical Address Line 2 After Transfer.

Text Field, 255 characters

Y

X

Material

Transfer

City

AN 255

Record Physical City After Transfer.

Text Field, 255 characters

Y

X

Material

Transfer

State

Dropdown

Record Physical State After Transfer.

Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Y

X

Material

Transfer

Zip

IN 5

Record Physical Zip After Transfer.

00000

Y

X

Material

Transfer

Zip+4

IN 4

Record Physical Zip+4 After Transfer.

0000

Y

X

Material

Transfer

County of Residence

Dropdown

Record Physical County After Transfer.

Counties displayed dependent on transfer state selection

Y

X

Material

Transfer

Comment

AN 2000

Record any additional comment regarding this transfer.

Text Field, 2000 characters

9123

Y

X

Non-material

Transfer

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

9123

N

Transfer

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

9123

N

Transfer

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

9123

N

Waiver Factors

Program Year

Dropdown

Record the program year for the waiver factors.

2011-2021

Y

X

Material

Waiver Factors

Severe Disability

IN 1

Record 1 if applicant has Severe Disability. Severe Disability is a severe, chronic disability attributable to mental or physical impairment, or a combination of mental and physical impairments, that (A) is likely to continue indefinitely, and (B) results in substantial functional limitation in 3 or more of the following areas of major life activity: (i) self-care, (ii) receptive and expressive language, (iii) learning, (iv) mobility, (v) self-direction, (vi) capacity for independent living, (vii) economic self-sufficiency.  Severe disability is to be recorded in addition to disability. Each is counted separately for the most-in-need measure. Severe disability must be documented by a physician. Record 0 if applicant does not the Severe Disability conditions.

1 = Yes 0 = No

2810

9120

Y

X

X

Waiver Factors

Last Updated Date

DT 8

Record most recent date that participant was deemed to have a severe disability. 'For each program year thereafter, enter the date of updating the factor if grantee wants to receive credit in the most-in-need measure or to use the factor to support a waiver request for the participant.

YYYYMMDD

2811

9120

Y

X

X

X

Non-material

Waiver Factors

Frail

IN 1

Record 1 if applicant is Frail. Frail means that an individual 55 years of age or older is determined to be functionally impaired because the individual: (A)(i) is unable to perform at least two activities of daily living without substantial human assistance, including verbal reminding, physical cueing, or supervision; or (ii) at the option of the grantee, is unable to perform at least three such activities without such assistance; or (B) due to a cognitive or other mental impairment, requires substantial supervision because the individual behaves in a manner that poses a serious health or safety hazard to him- or herself or to another individual. Frailty must be documented by a qualified professional. Record 0 if applicant does not meet the Frail definition.

1 = Yes 0 = No

2812

9120

Y

X

X

X

Non-material

Waiver Factors

Last Updated Date

DT 8

Record the date of updating the Frail waiver factor if you want to receive credit in the most-in-need measure or to use the factor to support a waiver request for the participant.

YYYYMMDD

2813

9120

Y

X

X

X

Non-material

Waiver Factors

Old Enough for but Not Receiving SS Title I

IN 1

Record 1 if an individual may qualify for SS retirement benefits at age 62. If an individual is 62 or over but does not have sufficient wage credits to qualify for retirement benefits. This factor applies only if the participant is not monetarily eligible for Social Security. Record 0 If the participant qualifies but chooses to delay receipt to increase the amount of benefits.

1 = Yes 0 = No

2814

9120

Y

X

X

X

Non-material

Waiver Factors

Last Updated Date

DT 8

Record the date of updating the Old Enough for but Not Receiving SS Title I waiver factor if you want to receive credit in the most-in-need measure or to use the factor to support a waiver request for the participant

YYYYMMDD

2815

9120

Y

X

X

X

Non-material

Waiver Factors

Severely Limited Employment Prospects in Area of Persistent Unemployment

IN 1

Record 1 if applicant is a severely limited employment prospects in area of persistent unemployment, This element has two separate requirements: 1. Severely limited employment prospects, and 2. Residence in an area of persistent unemployment. Both must be met for a “yes” answer. Severely limited employment prospects means a substantially higher likelihood that an individual will not obtain employment without the assistance of the SCSEP or another workforce development program. Persons with severely limited employment prospects have more than one significant barrier to employment; significant barriers to employment may include but are not limited to: lacking a substantial employment history, basic skills, and/or English-language proficiency; lacking a high school diploma or the equivalent; having a disability; being homeless; or residing in socially and economically isolated rural or urban areas where employment opportunities are limited. Persistent unemployment means that the annual average unemployment rate for a county or city is more than 20 percent higher than the national average for two out of the last three years. Record 0 if the applicant does not meet both conditions.

1 = Yes 0 = No

2816

9120

Y

X

X

Waiver Factors

Last Updated Date

DT 8

Record the date of updating the Severely Limited Employment Prospects in Area of Persistent Unemployment waiver factor to receive credit in the most-in-need measure or to use the factor to support a waiver request for the participant.

YYYYMMDD

2817

9120

Y

X

X

X

Non-material

Waiver Factors

Last Updated Date

DT 8

Record the date of updating the limited English proficiency waiver factor to receive credit in the most-in-need measure or to use the factor to support a waiver request for the participant.

YYYYMMDD

2819

9120

Y

X

X

X

Non-material

Waiver Factors

Last Updated Date

DT 8

Record the date of updating the low literacy skills waiver factor to receive credit in the most-in-need measure or to use the factor to support a waiver request for the participant.

YYYYMMDD

2821

9120

Y

X

X

X

Non-material

Waiver Factors

Last Updated Date

DT 8

Record the date of updating the formerly incarcerated waiver factor to receive credit in the most-in-need measure or to use the factor to support a waiver request for the participant.

YYYYMMDD

N

X

Material

Waiver Factors/Characteristics

Limited English Proficiency

IN 1

Record 1 if the participant cannot speak or read English well enough to fully participate in all aspects of the program. Record 0 if the participant is able to participate in all aspects of the program. An LEP individual is one who does not speak English as his or her primary language and who has a limited ability to read, speak, write, or understand English. If you are in doubt, ask the participant

1 = Yes 0 = No

2818

9120

Y

X

X

Waiver Factors/Characteristics

Low Literacy Skills

IN 1

Record 1 if the participant calculates or solves problems, reads, writes, or speaks English at or below the 8th grade level or is unable to compute or solve problems, read, write, or speak at a level necessary to function on the job, in the individual’s family, or in society. Record 0 if the participant does not meet above conditions.

1 = Yes 0 = No

2820

9120

Y

X

X

Waiver Factors/Characteristics

Formerly Incarcerated

IN 1

Record if the participant has been formerly incarcerated within the past 5 years of the date of eligibility determination.

Yes No

N

X

Material

Manage Re-Enrollment

Participant returned to SCSEP within the first 90 days of exit

IN 1

Record 1 if participant returned to SCSEP within the first 90 days of exit. Record 0 if participant did not returned to SCSEP within the first 90 days of exit.

1 = Yes 0 = No

2824

9122

Y

X

X

Manage Re-Enrollment

Has the participant re-enrolled in SCSEP within the first 90 days after exit?

IN 1

Record 1 if the participant re-enrolled in SCSEP within the first 90 days after exit. Record 0 if the participant did not re-enroll in SCSEP within the first 90 days after exit.

1 = Yes 0 = No

2825

9122

Y

X

X

X

Non-Material

Manage Re-Enrollment

Date of Return

DT 8

Record the date the participant returned to SCSEP within the first 90 days of exit.

YYYYMMDD

Y

X

Material

Manage Re-Enrollment

Date of Re-Enrollment

DT 8

Record the date the participant re-enrolled in SCSEP within the first 90 days of exit.

YYYYMMDD

Y

X

Material

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Sheet 3: Job and Exit Codes

General CSA Code	Elderly CSA Code	Job Code	Other Reason for Exit	Exclusions at Exit
G1. Education	E1. Project Administration	Management Occupations	Moved from area	Ineligible at Recertification due to income
G2. Health and Hospitals	E2. Health and Home Care	Business and Financial Operations Occupations	For cause	Reserve Forces called to Active Duty
G3. Housing and Home Rehabilitation	E3. Housing and Home Rehabilitation	Computer and Mathematical Occupations	Voluntary	Deceased
G4. Employment Assistance	E4. Employment Assistance	Architecture and Engineering Occupations	Durational limit	Participant's Health/medical
G5. Recreation, Parks, and Forest	E5. Recreation/Senior Centers	Life, Physical, and Social Science Occupations	Exclusions at Exit	Institutionalized
G6. Environmental Quality	E6. Nutrition Programs	Community and Social Service Occupations
G7. Public Works and Transportation	E7. Transportation	Legal Occupations
G8. Social Services	E8. Outreach/Referral	Educational Instruction and Library Occupations
G9. Lgal	E9. Legal	Arts, Design, Entertainment, Sports, and Media Occupations
G10. Financial	E10. Financial	Healthcare Practitioners and Technical Occupations
G11. Counseling	E11. Counseling	Healthcare Support Occupations
G12. Conservation	E12. Conservation	Protective Service Occupations
G13. Community Betterment	E13. Community Betterment	Food Preparation and Serving Related Occupations
G14. Other	E14. Other	Building and Grounds Cleaning and Maintenance Occupations
		Personal Care and Service Occupations
		Sales and Related Occupations
		Office and Adminstrative Support Occupations
		Farming, Fishing, and Forestry Occupations
		Construction and Extraction Occupations
		Installation, Maintenance, and Repair Occupations
		Production Occupations
		Transporation and Material Moving Occupations
		Military Specific Occupations
		Self Employment

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Sheet 4: Reservations, Tribal Affil

Tribal Affiliations, AR	Tribal Affiliations, TX	Tribal Affiliations, MS	Tribal Affiliations, LA	Tribal Affiliations, WI	Tribal Affiliations, SD	Tribal Affiliations, OK	Tribal Affiliations, NM	Tribal Affiliations, ND	Tribal Affiliations, MN	Tribal Affiliations, AZ	Reservations
Chicgasaw/Mississippi Choctaw	Coushatta,	Choctaw	Coushatta	Minominee Tribe	Sioux Tribe	Osage	Mescalero Apache	Spirit Lake Tribe	Fond du Lac Band of Lake Superior Chippewa	Ak Chin	Coushatta Reservation
Yurok/Karuk Cherokee	Apache	Mississippi Band of Choctaw	Tunica-Biloxi	Oneida Tribe	Cheynne River Sioux	Cherokee	Pueblo	Sioux	Shakopee Mdewakanton Sioux Community	Hopi & Navajo	Tunica-Biloxi Reservation
Yupik	Alabama Coushatta	Other (Specify: )	Chitimacha	Lake Superior Tribe of Chippewa Indians	Oglala Lakota Sioux	Muscogee	Ute Mountain Tribe	Mandan, Hidatsa and Arikara	Lower Sioux Tribe	Apache	Chitimacha Reservation
Pawnee	Choctaw	N/A	Choctaw	Potawatomi Tribe	Sicangu Sioux	Iowa	Navajo	Turtle Mtn. Band of Chippewa Indians	Prairie Island Tribe	Tohono O'Odham Tribe	Jena Band of Choctaw
Apache	Creek		United Houma Nation	Ho-Chunk Nation	Sioux Tribe	Sac	Other (Specify: )	Other (Specify: )	Sioux Indians	Pascua Yaqui Tribe	Choctaw Indian Reservation
Quapaw	Navajo		Other (Specify: )	Other (Specify: )	Sioux Tribe	Fox	N/A	N/A	Other (Specify: )	Pima and Maricopa Tribes	Alabama-Coushatta
muskogee Creek	Other (Specify: )		N/A	N/A	Crow Tribe	Kickapoo			N/A	Pima and Maricopa Tribes	Ak Chin Indian Reservation
Seminole	N/A				Lower Brule Sioux Tribe	Potawotomi				Mohave- Apache - Ak Chin	Navajo Indian Reservation
Osage					Flandreau Santee Sioux Tribe	Absentee Shawnee				Havasupai Tribe	San Carlos Reservation
Assiniboine					Other (Specify: )	Seminole				Paiute Indians	Tohono O'Odham Reservation
Sioux					N/A	Choctaw				Quechan Tribe	Pascua Yaqui Reservation
Navajo						Kiowa				White Mountain Apache Tribe	Gila River Reservation
Chippewa						Comanche				Yavapai-Apache Tribe	Salt River Reservation
Blackfeet						Apache				Yavapai-Prescott Indian Tribe	Havasupai Reservation
Caddo						Other (Specify: )				San Juan Southern Paiute Tribe	Kaibab Indian Reservation
Cheyenne						Alabama-Quassarte Tribe				Tonto Apache Tribe	Fort Yuma Indian Reservation
Arapaho						Cheyenne				Cocopah Tribe	Fort Apache Reservation
Quapaw						Arapaho				Dolorado River Indian Tribe	Camp Verde Indian Reservation
Choctaw						Delaware Nation				Fort McDowel Yavapai Nation	Fond du Lac Reservation
Other (Specify: )						Eastern Shawnee				Fort Mojave Indian Tribe	Mdewakanton Reservation
N/A						Iowa Tribe				Other (Specify: )	Lower Sioux Indian Community
						Kaw Nation				N/A	Prairie Island Tribe Community
						Kialegee Tribe					Upper Sioux Community
						Kickapoo Tribe					Spirit Lake Reservation
						Kiowa Tribe					Standing Rock Reservation
						Miami Tribe					Fort Berthold Reservation
						Modoc Tribe					Acoma Pueblo
						Muscogee Nation					Cochiti Pueblo
						Ottawa Tribe					Isleta Pueblo
						Otoe-Missouria Tribe					Jemez Pueblo
						Pawnee Nation					Laguna Pueblo
						Peoria Tribe					Mescalero Apache Reservation
						Ponca Tribe					Nambe Pueblo
						Quapaw Tribe					Ohkay Owingeh Pueblo
						Sac & Fox Nation					Picuris Pueblo
						Shawnee Tribe					Pojoaqui Pueblo
						Thlopthlocco Tribe					San Felipe Pueblo
						Tonkawa Tribe					San Ildefonso
						United Keetoowah Band of Cherokee Indians					Sandia Pueblo
						Wichita Tribe					Santa Ana Pueblo
						Keechi Tribe					Santa Clara Pueblo
						Waco Tribe					Santo Domingo Pueblo
						Tawakonie Tribe					Taos Pueblo
						Wyandotte Nation					Tesuque Pueblo
						Other (Specify: )					Ute Mountain Reservation
						N/A					Zia Pueblo
											Zuni Pueblo
											Navajo Reservation
											Ramah Navajo Reservation
											To'hajiilee Navajo Reservation
											Cheynne River Reservation
											Pine Ridge Reservation
											Rosebud Reservation
											Yankton Sioux Reservation
											Lake Traverse Reservation
											Crow Creek Reservation
											Lower Brule Reservation
											Stockbridge-Munsee Reservation
											Oneida Reservation
											Bad River Reservation
											Forest County Potawatomi Community
											N/A

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Sheet 5: Education and Training

Category	Type	Type (Sub Category)	Possible one day trainings
Education and Training	Specialized Training (Specific Job/Industry)
Education and Training	General training (Basic Skills)
Education and Training	On-the-Job-Experience (OJE)
Education and Training	Other (Specify)	Text Box
Education and Training	Apprenticeship Training
Education and Training	Educational Remediation and Literacy	Adult Education
Education and Training	Educational Remediation and Literacy	ESL
Education and Training	Educational Remediation and Literacy	Other
Education and Training	Computer Training (e.g.,Computer Literacy Training)		X
Supportive Service	Transportation Assistance		X
Supportive Service	Incidentals such as work shoes, badges, uniforms, eyeglasses, and tools		X
Supportive Service	Food Assistance		X
Supportive Service	Housing (e.g.,Temporary Housing Assistance)		X
Supportive Service	Dependent Care (e.g., Child or Adult Care Assistance)		X
Supportive Service	Health and Medical Services (e.g., RX, Eye Glasses, medical test)		X
Supportive Service	Needs-related Payment (e.g., Utilities)		X
Supportive Service	Special Job-related or Personal Counseling		X
Supportive Service	Educational or Occupational Licensing and Testing Fees		X
Supportive Service	Other (Specify)	Text Box	X
Follow-Up Services (Other than supportive service)	Help Participant Get Another Job
Follow-Up Services (Other than supportive service)	Intervention with Employer
Follow-Up Services (Other than supportive service)	Counsel Participant on Job-Related Issues
Follow-Up Services (Other than supportive service)	Referrals (Drop down: all the referrals)	Additional Training
Follow-Up Services (Other than supportive service)	Referrals	Employment Assistance
Follow-Up Services (Other than supportive service)	Referrals	Other (Specify)