Health and Wellness

Standard Job Corps Contractor Information Gathering

Documents and Forms

Document Name Document Type
Form ETA 9222 Health and Wellness Form
ETA 9222 Health and Wellness Center Annual Program Description ETA 9222 Health and Wellness Center Annual Program Description APD.docx Form
ETA 9212 Alcohol Testing Report ETA 9212 Alcohol Testing Report.docx Form
ETA 9214 Social Intake Form ETA 9214 Social Intake Form_EO 14168 Changes.docx Form
ETA 9216 Health History Form ETA 9216 Health History Form_EO 14168 Changes.docx Form
ETA 9217 Lab Testing Information Sheet ETA 9217 Laboratory Testing Information Sheet.docx Form
ETA 9213 Immunization Record ETA 9213 Immunization Record_Updated.docx Form
ETA 9215 Physical Examination Form ETA 9215 Physical Examination Form_Updated_EO 14168 Changes.docx Form

Information Collection (IC) Details

IC Title:	Health and Wellness	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 686

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	ETA 9222	Health and Wellness Center Annual Program Description	ETA 9222 Health and Wellness Center Annual Program Description APD.docx	Yes	Yes	Fillable Fileable
Form	ETA 9212	Alcohol Testing Report	ETA 9212 Alcohol Testing Report.docx	Yes	Yes	Fillable Fileable
Form	ETA 9214	Social Intake Form	ETA 9214 Social Intake Form_EO 14168 Changes.docx	Yes	Yes	Fillable Fileable
Form	ETA 9216	Health History Form	ETA 9216 Health History Form_EO 14168 Changes.docx	Yes	Yes	Fillable Fileable
Form	ETA 9217	Lab Testing Information Sheet	ETA 9217 Laboratory Testing Information Sheet.docx	Yes	Yes	Fillable Fileable
Form	ETA 9213	Immunization Record	ETA 9213 Immunization Record_Updated.docx	Yes	Yes	Fillable Fileable
Form	ETA 9215	Physical Examination Form	ETA 9215 Physical Examination Form_Updated_EO 14168 Changes.docx	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title: DOL/GOVT-2. (Job Corps Student Records)	FR Citation: 67 FR 16815

Number of Respondents: 847	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	179,105	179,105
Annual IC Time Burden (Hours)	89,458	89,458
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.