Form ETA 9136 ETA 9136 MIS System, Quarterly Report

STANDARDIZED QUARTERLY PERFORMANCE REPORT

YouthBuild (YB) GRANT

ETA - 9136

OMB No.

1205-0464

Report Due Date: mm/dd/yyyy

Expires:

xx/xx/xxxx

A. GRANTEE IDENTIFYING INFORMATION

Grantee Name:

Grant Number:

Program/Project Name:

Project or Sub-Project ID/Number:

Report Quarter End Date:

City ________________________________

State ______

Zip Code __________

Enrollment Goal:

Performance Items

Previous Quarter (A)

Current Quarter (B)

Cumulative for Program Year (C)

Program-to-Date (D)

B. PARTICIPANT SUMMARY INFORMATION

1. Total Exiters

2. Total Participants Served

3. New Participants Served

Gender

4a. Male

4b Female

Ethnicity / Race

5a. Hispanic/Latino

5b. American Indian or Alaska Native

5c. Asian

5d Black or African American

5e. Hawaiian Native or Other Pacific Islander

5f. White

Education Level

6a. 8th grade and under

6b. 9th grade - 12th grade

6c. High School graduate or equivalent

6d. 1 - 3 years of college, or full-time technical or vocational school

6e. 4 years college or more

Other Demographics

7. Limited English Proficient

8. Low Income

9. Foster Youth

10. Migrant Youth

11. High School Drop-Out

12. Youth Offender

13. Adult Offender

14. Basic Skills Deficient

15. Child of Incarcerated Parent

16. Persons with a Disability

17. Not Employed at Program Enrollment

Performance Items

Previous Quarter (A)

Current Quarter (B)

Cumulative for Program Year (C)

Program-to-Date (D)

Value

Numerator

Value

Numerator

Value

Numerator

Value

Numerator

Denominator

Denominator

Denominator

Denominator

C. PROGRAM SERVICES, ACTIVITIES, AND OTHER RELATED ASSISTANCE

1. Received Education or Job Training Activities

2. Received Workforce Preparation Activities

3. Community Involvement & Leadership Development Activities

4. Post Secondary Exploration and Planning Activities

5. Received Mentoring Activities

6. Received Health Services

7. Received Supportive Services

D. SHORT-TERM INDICATORS OF PERFORMANCE

Leading Indicators of Performance

1. Enrollment Rate

2a. Number of Initial Job Placements

2b. Average Hourly Wage Rate at Placement

2c. Number of Job Re-Placements

2d. Average Hours Worked 1st Week of Placement

3. Number Obtained High School Diploma or GED

4. Number Obtained a Certificate

5. Entered Post Secondary Education

6. Entered Vocational/Occupational Skills Training

7. Entered Pre-Apprenticeship

8. Entered Registered Apprenticeship

E. LONG-TERM INDICATORS OF PERFORMANCE

Common Performance Measures

1. Placement in Education or Employment

2. Attainment of a Degree Or Certificate

3. Literacy and Numeracy Attainment

Additional Performance Measures

4. Recidivism Rate

5. Retention Rate

F. REPORT CERTIFICATION/ADDITIONAL COMMENTS

Grantee Remarks:

Name of Grantee Certifying Official:

Telephone Number:

Email:

This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0464. Persons are not required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this collection of information is estimated to average 16 hours per quarterly report per grantee, including time for reviewing instructions, searching existing data sources, gathering and reviewing the collection of information. Respondent’s obligation to reply is required to maintain benefits. The reason for the collection of information is general program oversight, evaluation and performance assessment. Send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden, to the U. S. Department of Labor, Employment and Training Administration, Youth Office, Room N4459, 200 Constitution Avenue, NW, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0464).