Form ETA-9120 SCSEP Participant Data Form

SCSEP Participant Form

Participant Information

1. Last name ______________________ 2. First name

3. Middle initial 4. Social Security #

5. Home phone number (_____) ________________

6. Mailing address

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

b. City c. State

d. ZIP Code e. County

6a. Participant’s e-mail address ______________________________________________

6b. Emergency contact: Name_________________ Phone (____) _________________

Relationship ________________________________

7. State of residence if different from mailing address ____________________________

8. Homeless Yes No 8a. Urban/rural Urban Rural

9. Application date for enrollment or re-enrollment ____________________(MM/DD/YYYY)

Eligibility Information

10. Date of birth________________(MM/DD/YYYY) 11. Number in family______

12. Receiving public assistance? (Check as many as apply)

a. No b. Supplemental Security Income (SSI)

c. TANF d. State or local welfare (General Assistance)

e. Food Stamps f. Subsidized housing

g. Social Security Disability (SSDI) h. Other (specify)_____________________

Authorized for Local Reproduction ETA-9120

(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, Office of National Programs, Room C-4312, Washington, DC 20210 (Paperwork Reduction Project 1205-0040).

13. Employed prior to participation?

i. Employed ii. Employed, but with notice of termination iii. Not employed

14. Total includable family income (12-month or 6-month annualized) $______________

15. Family income at or below 100% of poverty level? Yes No

16. Formerly a participant in any SCSEP project? Yes No

17. *Transferred from another project? Yes No

If yes, specify prior grantee code _____________________________________

Date of transfer ____________________________

17a. *Change of sub-grantee? Yes No

If yes, specify prior sub-grantee code __________________________________

Date of change __________________________

Other Personal Characteristics and Information

18. Gender Male Female Did not voluntarily report

19. Ethnicity: Hispanic, Latino, or Spanish origin?

Yes No Did not voluntarily report

20. Race (Check as many as apply)

a. American Indian or Alaskan Native b. Asian

c. Black, African American d. Native Hawaiian/Pacific Islander

e. White f. Did not voluntarily report

21. Education ________ last grade completed (Select one code from following list)

00=no grade school	88=GED or certificate of equivalency for HS	18=master's degree
1-11 years of school	13-15 years of school completed (1-3 years of college)	19=doctoral degree
A11=completed 12 years of school but no HS diploma	16=BA/BS or equivalent	21=vocational/technical degree
12=HS diploma	17=education beyond a bachelor's degree	22=associate's degree

22. Limited English Proficiency (LEP) Yes No

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

23. If LEP, please specify primary language _____ (Select one code from following list)

10. Amharic 20. Hebrew 30. Mon-Khmer (Cambodian) 40. Spanish

11. Arabic 21. Hindi 31. Navajo 41. Tagalog

12. Armenian 22. Miao (Hmong) 32. Persian (including Dari) 42. Thai

13. Bosnian 23. Italian 33. Polish 43. Urdu

14. Cantonese (Yue) 24. Hungarian 34. Portuguese 44. Vietnamese

15. French 25. Ilocano 35. Punjabi 45. Yiddish

16. French Creole 26. Japanese 36. Russian 46. Other_____

17. German 27. Korean 37. Samoan ____________

18. Greek 28. Laotian 38. Serbo-Croatian

19. Gujarathi 29. Mandarin 39. Somali

24. Low literacy skills? Yes No

25. Veteran (or qualified spouse of veteran)?

a. Non-qualified veteran b. Qualified veteran

c. Qualified spouse of veteran d. None of above

26. Disability? Yes No Did not voluntarily report

27. At risk of homelessness? Yes No

28. Displaced homemaker? Yes No

29. Failed to find employment after using WIA Title I? Yes No

30. Low employment prospects? Yes No

31. Personal characteristics comments

Certification

I hereby certify that the above information is true and accurate to the best of my knowledge and belief. I understand that if I intentionally provide inaccurate information, I may be terminated from the SCSEP program and may be subject to legal penalties.

32. Signature of applicant

______________________________________

33. Date of signing

_______________________ (MM/DD/YYYY)

Eligibility Determination

34. Eligible Ineligible

35. If ineligible, reason (Check as many as apply)

a. Age b. Income c. Residence outside of state

d. Failed to complete application or provide required documentation

e. Other (specify) ________________________________________

36. If ineligible, action taken (Check as many as apply)

a. Referred to One-Stop b. Referred to social services

c. Referred to another project

d. Placed in unsubsidized employment pursuant to MOU

e. Other (specify) _________________________________________

Enrollment Information

37. Placed on waiting list? Yes No

38. Community service assignment? Yes No

39. Grantee name __________________________________________________

39a. County of authorized position _____________________________________

40. Co-enrollments? (Check as many as apply)

a. WIA b. Employment Service c. Adult Education

d. College/Community College

e. Other (specify) ____________________________________________________

f. None

40a. Date of orientation _______________________ (MM/DD/YYYY)

40b. Date of last physical or waiver ______________________ (MM/DD/YYYY)

40c. Date of last IEP __________________________ (MM/DD/YYYY)

40d. Job interest codes: 1________ 2 ________ 3________

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

41. Enrollment comments

42. Signature of director or authorized representative

____________________________________________

43. Date of eligibility determination

__________________________(MM/DD/YYYY)

43a. Is participant deceased? Yes No

Recertification

44. Number in family______

45. Total includable family income (12-month or 6-month annualized) $_____________

Certification

I hereby certify that the above information is true and accurate to the best of my knowledge and belief. I understand that if I intentionally provide inaccurate information, I may be terminated from the SCSEP program and may be subject to legal penalties.

46. Signature of participant on recertification ____________________________

47. Eligible Ineligible

48. If ineligible, reason (Check as many as apply)

a. Income b. Failed to complete application or provide required documentation

c. Other (specify) ________________________________________

49. Signature of director or authorized representative on recertification

­ ______________________________________

50. Date of recertification determination ______________________ (MM/DD/YYYY)

Waiver of Durational Limit

51. Severe disability? Yes No

52. Frail? Yes No

53. Old enough for but not receiving SS Title II? Yes No

54. Severely limited employment prospects in area of persistent unemployment?

Yes No

55. *Limited English Proficiency (LEP)? Yes No

56. *Low literacy skills? Yes No

57. *75 or over? Yes No

5 8. Recertification/waiver comments

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

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