Form ETA-9121 SCSEP Community Service Assignment Form

SCSEP Community Service OMB Approval Number: 1205-0040

Assignment Form Expiration Date: 08/31/09

1. Name of participant 2. S.S. #

3. Grantee

Host Agency Information

4. Name of host agency

5. Host agency mailing address

a. Number and Street, Suite Number; or PO Box

b. City

c. State d. Zip code

6. FEIN

7. Host agency type: Not-for-profit Government

7a. Date of host agency agreement _______________________ (MM/DD/YYYY)

7b. Date of host agency monitoring visit _______________________ (MM/DD/YYYY)

8. Host agency site name and location

8a. Host agency job codes: i ________ ii ________ iii ________

1. Art, Design, Entertainment, Sports, and Media	8. Food Preparation and Service	15. Production, Assembly, Light Industrial
2. Business and Financial Operations	9. Healthcare	16. Protective Service
3. Community and Social Services	10. Legal	17. Retail, Sales, and Related
4. Computer and Mathematical	11. Maintenance and Custodial	18. Self-Employment
5. Construction, Installation, and Repair	12. Management	19. Transportation and Material Moving
6. Education, Training, and Library	13. Office and Administrative Support
7. Farming, Fishing, and Forestry	14. Personal Care and Service

Authorized for Local Reproduction ETA-9121

(Revised July 2007)

This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0040, expiring 08/31/2009. 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 six (6) 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. If you have any comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden; send them to the U.S. Department of Labor, Office of National Programs, Room C-4312, Washington, DC 20210 (Paperwork Reduction Project 1205-0040).

8b. Host agency continued availability Available Not available

Contact/Supervisor Information

9. Name of contact person

10. Contact person’s mailing address if different from number 5

_____________________________________________________________________

a. Organization or address field 1

_____________________________________________________________________

b. Number and Street, Suite Number; or PO Box or address field 2

_____________________________________________________________________

c. City

_____________________________________________________________________

d. State e. Zip Code

11. Contact person’s title

11a. Contact person’s salutation Mr. Ms.

12. Contact person’s phone number

12a. Contact person’s fax number

12b. Contact person’s e-mail address

Complete fields 12c-12j if supervisor is different from contact person (number 9). If supervisor is the same as contact person, skip to field 12j.

12c. Name of supervisor

12d. Supervisor’s mailing address if different from number 5

a. Organization or address field 1

_____________________________________________________________________

b. Number and Street, Suite Number; or PO Box or address field 2

c. City

d. State e. Zip Code

12e. Supervisor’s title

12f. Supervisor’s salutation Mr. Ms.

12g. Supervisor’s phone number

12h. Supervisor’s fax number

12i. Supervisor’s e-mail address

12j. Funding source of supervisor or contact person/supervisor:

Federal Non-federal $_______ (hourly rate) _______ (average hours per week)

Assignment Information

13. Assignment date (MM/DD/YYYY)

14. Start assignment date (MM/DD/YYYY)

15. End date (MM/DD/YYYY)

15a. Approved break in participation

Start date _________ (MM/DD/YYYY) Expected end date________ (MM/DD/YYYY)

Actual end date__________ (MM/DD/YYYY)

15b. Reason for approved break in participation

i. Family/health	iii. Administrative
ii. Personal	iv. Other (specify)________________

16. CSA wage (per hour) $

16a. Number of hours per week assigned ____________

16b. Participant’s schedule

16c. Date of safety consultation with participant ________________ (MM/DD/YYYY)

17. Community service assignment code (Select only one code from following lists)

Service to the general community includes the following activities:

G1. Education	G6. Environmental Quality	G11. Counseling
G2. Health and Hospitals	G7. Public Works & Transportation	G12. Conservation
G3. Housing and Home Rehabilitation	G8. Social Services	G13. Community Betterment
G4. Employment Assistance	G9. Legal	G14. Other_______________
G5. Recreation, Parks, and Forests	G10. Financial

Service to the elderly community includes the following activities:

E1. Project Administration	E6. Nutrition Programs	E11. Counseling
E2. Health and Home Care	E7. Transportation	E12. Conservation
E3. Housing and Home Rehabilitation	E8. Outreach/Referral	E13. Community Betterment
E4. Employment Assistance	E9. Legal	E14. Other_______________
E5. Recreation/Senior Centers	E10. Financial	________________________

18. Community service assignment title

18a. Participant’s job code___________

1. Art, Design, Entertainment, Sports, and Media	8. Food Preparation and Service	15. Production, Assembly, Light Industrial
2. Business and Financial Operations	9. Healthcare	16. Protective Service
3. Community and Social Services	10. Legal	17. Retail, Sales, and Related
4. Computer and Mathematical	11. Maintenance and Custodial	18. Self-Employment
5. Construction, Installation, and Repair	12. Management	19. Transportation and Material Moving
6. Education, Training, and Library	13. Office and Administrative Support
7. Farming, Fishing, and Forestry	14. Personal Care and Service

18b. Participant’s workers’ compensation code___________

19. Total hours paid in quarter

Quarter 1	Quarter 3
Quarter 2	Quarter 4

20. Types of training received (Check all that apply)

a. General training (basic skills)	d. Other (specify)______________
b. Specialized training (specific job/industry)	e. None
c. On-the job-experience (OJE)

21. Total hours of paid training received in quarter

Quarter 1	Quarter 3
Quarter 2	Quarter 4

22. Community service assignment comments

Sub-Grantee Provided Training Information

Training Provider Information

23. Name of training provider or OJE employer

24. Training provider or OJE employer mailing address

a. Number and Street, Suite Number; or PO Box

b. City

c. State d. Zip code

25. Training provider continued availability Available Not available

Contact Person Information

26. Name of training provider or OJE employer contact person

27. Contact person’s mailing address if different from number 24

a. Organization or address field 1

_____________________________________________________________________

b. Number and Street, Suite Number; or PO Box or address field 2

c. City

d. State e. Zip Code

28. Contact person’s title

29. Contact person’s salutation Mr. Ms.

30. Contact person’s phone number

31. Contact person’s fax number

32. Contact person’s e-mail

Training Information

33. Types of training received (Check only one per training record)

a. General training (basic skills)	d. Other (specify)_________________
b. Specialized training (specific job/industry)
c. On-the job-experience (OJE)

34. Job code for which training is provided, if relevant ___________

1. Art, Design, Entertainment, Sports, and Media	8. Food Preparation and Service	15. Production, Assembly, Light Industrial
2. Business and Financial Operations	9. Healthcare	16. Protective Service
3. Community and Social Services	10. Legal	17. Retail, Sales, and Related
4. Computer and Mathematical	11. Maintenance and Custodial	18. Self-Employment
5. Construction, Installation, and Repair	12. Management	19. Transportation and Material Moving
6. Education, Training, and Library	13. Office and Administrative Support
7. Farming, Fishing, and Forestry	14. Personal Care and Service

35. Participant’s workers’ compensation code in training ___________

36. Start training date (MM/DD/YYYY)

37. End training date (MM/DD/YYYY)

38. Average number of hours of training per week___________

39. Average number of hours of community service per week during training_________

40. If OJE, wages paid by:

Sub-grantee Employer and reimbursed by sub-grantee at rate of _____%

41. Training wage (per hour) $

42. Total wages paid to participant or reimbursed to employer $__________________

43. Total amount paid to training provider for provision of training (other than reimbursement to employer) $________________

44. Training Comments

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