Form ETA-9122 SCSEP Unsubsidized Employment Form

SCSEP Participant Form

1. Name of participant___________________ 2. S.S. #

Employer Information

3. Name of employer

4. Employer mailing address

a. Number and street, suite number; and/or PO Box

b. City

c. State d. ZIP code

5. FEIN_____________________________

6. Employer type

Not-for-profit For-profit

Government Self-employment

7. Is employer a host agency? Yes No

8. Did employer provide an OJE training site for this participant? Yes No

9. Employment site name and location________________________________________

9a. *Employer received customer satisfaction survey in PY _________

9b. Employer continued availability Available Not available

*No data entry in SPARQ. Field is system-generated.

Authorized for Local Reproduction ETA-9122

(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 twelve (12) 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, Division of Adult Services, Room S-4203, 200 Constitution Avenue, NW, Washington, DC 20210 (Paperwork Reduction Project 1205-0040).

Contact/Supervisor Information

10. Name of contact person

11. Contact person’s mailing address if different from number 4

__________________________________________________________________________________

a. Organization name or address field 1

__________________________________________________________________________________

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

__________________________________________________________________________________

c. City

__________________________________________________________________________________

d. State e. ZIP Code

12. Contact person’s title

12a. Contact person’s salutation Mr. Ms.

13. Contact person’s phone number

13a. Contact person’s fax number

13b. Contact person’s e-mail address

Complete fields 13c-13i if supervisor is different from contact person (number 10). If supervisor is the same as contact person, skip to field 14.

13c. Name of supervisor

13d. Supervisor’s mailing address if different from number 4

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

13e. Supervisor’s title

13f. Supervisor’s salutation Mr. Ms.

13g. Supervisor’s phone number

13h. Supervisor’s fax number

13i. Supervisor’s e-mail address

Placement Information

14. Start date_______________________(MM/DD/YYYY)

15. End date_______________________(MM/DD/YYYY)

16. Starting wage per hour $_____________________

17. Benefits (check all that apply)

a. Health insurance	d. Vacation	g. Other__________(specify)
b. Sick leave	e. Transportation	h. None
c. Pension/profit sharing	f. Room and board

18. At time of placement, is employment expected to be full- or part-time?

Full-time Part-time

If part-time, number of hours per week expected

19. Job title

19a. 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

19b. High-growth placement

1. Automotive	6. Financial Services	11. Retail
2. Advanced Manufacturing	7. Geospatial	12. Transportation
3. Biotechnology 4. Construction 5. Energy	8. Health Care 9. Hospitality 10. Information Technology	13. None

20. Training-related placement? Yes No

21. Was placement the result of a substantial service provided to the employer by the sub-grantee? Yes No

22. Unsubsidized employment comments

Customer Service Survey Information

23. CS survey number 1 Date _____________ (MM/DD/YYYY)

24. CS survey number 2 Date _____________ (MM/DD/YYYY)

25. CS survey number 3 Date _____________ (MM/DD/YYYY)

Follow-up Information

26. *90-day date (MM/DD/YYYY)

27. Has the participant returned to program within the first 90 days after exit?

Yes No

27a. Has the participant re-enrolled in SCSEP within the first 90 days after exit?

Yes No

28. Follow-up 1

a. *Scheduled date____________________ (MM/DD/YYYY)

b. Completed date____________________(MM/DD/YYYY)

c. Any wages for first quarter after exit quarter? Please also indicate method of verification

1. No wages

2. Yes, in-state UI records only

3. Yes, out-of-state UI records (WRIS) only

4. Yes, both in- and out-of-state UI records

5. Yes, other administrative records

6. Yes, supplemental through case management, participant survey, and/or verification

with the employer

7. Unable to obtain information

8. Excluded

29. Follow-up 2

1. *Scheduled date (MM/DD/YYYY)

2. Completed date (MM/DD/YYYY)

3. Any wages for second quarter after exit quarter? Please also indicate method of verification

   1. No wages

   2. Yes, in-state UI records only

   3. Yes, out-of-state UI records (WRIS) only

   4. Yes, both in- and out-of-state UI records

   5. Yes, other administrative records

   6. Yes, supplemental through case management, participant survey, and/or verification

with the employer

7. Unable to obtain information

8. Excluded

*No data entry in SPARQ. Field is system-generated.

4. If yes, earnings for second quarter after exit quarter $__________________

5. Any wages for third quarter after exit quarter? Please also indicate method of verification

   1. No wages

   2. Yes, in-state UI records only

   3. Yes, out-of-state UI records (WRIS) only

   4. Yes, both in- and out-of-state UI records

   5. Yes, other administrative records

   6. Yes, supplemental through case management, participant survey, and/or verification

with the employer

7. Unable to obtain information

8. Excluded

1. If yes, earnings for third quarter after exit quarter $_______________

30. Follow-up 3

a. *Scheduled date____________________ (MM/DD/YYYY)

b. Completed date____________________(MM/DD/YYYY)

c. Any wages for fourth quarter after exit quarter? Please also indicate method of verification

1. No wages

2. Yes, in-state UI records only

3. Yes, out-of-state UI records (WRIS) only

4. Yes, both in- and out-of-state UI records

5. Yes, other administrative records

6. Yes, supplemental through case management, participant survey, and/or verification

with the employer

7. Unable to obtain information

8. Excluded

*No data entry in SPARQ. Field is system-generated.

* Designates a field that must be completed for all applicants regardless of eligibility 3