ETA 661 Student Separation

U.S. Department of Labor Employment and Training Administration Office of Job Corps

ETA 661 OMB Control No. 1205-0219 Expiration Date: 05/31/2025

Student Separation

Purpose of this form: The form documents a student’s separation data including reason for separation, contact information, and activities completed while at JC (e.g., GED, graduated).

Separate Student

Legal Name			Student ID
Sex	☐ Male ☐ Female		Admissions Representative
Date of Birth
Address			Final Pay Address
Address 1			Address 1
Address 2			Address 2
City			City
State			State
Country			Country
Zip			Zip
Phone			Phone
			Ext.
Separation Information			Separation Checklist
Projected Separation Date			Number of Paid Days
Separation Type			GED Status
Separation Season			Vocation Completion Status
Readjustment Pay for MSWR			Graduate
Recommend to Job Corps	☐		Eligible for Placement Service
Accept Readmit to Same Center	☐		Driver’s License
Eligible for Placement			Unpaid Debt Amount
Placer			Last TABE Test Date

Paperwork Reduction Act Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 113-128). Public reporting burden is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0219). Please do not submit completed forms to this address.

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