ETA 9085 SUpplemental Youth Services Report

INDIAN AND NATIVE AMERICAN YOUTH PROGRAM

(including youth served under the American Recovery and Reinvestment Act)

OMB Control No: 1205-0422
Expires 2/ 28 / 2010

SECTION I - Grantee Identifying Information
Grantee Name and Address:

Grant Number:

___________________________________________________________________________________

Report End Date:
_______ / _______ / _________

Previous Period
(A)

Current Period
(B)

SECTION II - Participation / Exiter Summary - [Enter participants who enrolled in the program and Exited during the program year.]
1. Total Participants
a. Participation in Summer Employment
2. Total Exiters
a. Summer Employment Exiters
3. Total Current Participants

Gender

SECTION III - Participant Characteristics Summary - [Enter characteristics of participants at enrollment]
4. Male
5. Female

Education
n

6. High School / Pre-High School Student
7. High School Graduate or Equivalent
8. Post High School Student
9. School Dropout
10. Pregnant and/or Parenting Youth
11. Offender

Barriers

12. Foster Child
13. Public Assistance Recipient
14. Basic Skills Deficiency

School
Status

15. Individual With Disability
16. In-school youth
17. Out-of-school youth

Age

18. 14 - 18
19. 19 - 21
20. 22 - 24 (Recovery Act Participants Only)
VETS 21. Eligible Veterans

Program-to-Date
(C)

SECTION IV - Participant Goals and/or Attainments Summary - [Enter goals attained after receiving program services]
22. Completed Work Readiness
23. Completed Internship or Vocational Exploration Program
24. Completed Career Assesment
25. Entered Unsubsidized Employment (Including Military)
26. Remained in School
27. Returned to School Full Time
28. Enrolled in Job Corps
29. Improved Basic Skills by at Least Two Grade Levels
30. Attained High School Diploma
31. Attained GED
32. Completed Occupational Skills Training
33. Completed Leadership Skills Training
34. Entered Other (Non-Supplemental Youth) Training Program
35. Successful Completion of Summer Employment

SECTION V. Performance Outcomes / Performance

Value

Numerator
Denominator

Value

Numerator
Denominator

Value

Numerator
Denominator

36. Attainment of Two or More Goals

37. Educational Attainment for Dropouts

SECTION VI. Recovery Act - Indicators of Performance

Value
a ue

Numerator
Denominator
Denominator

Value
a ue

Numerator
Denominator
Denominator

Value
a ue

Numerator
Denominator
Denominator

38. Work Readiness Attainment Rate

39. Summer Employment Completion Rate
Grantee Remarks

Certification: I Certify that to the best of my knowledge and belief that this report is correct and complete for the purpose set forth in
the Grant Agreement.
Name of Grantee Certifying Official:

Telephone Number:

Email:

Public Burden Statement: This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0422. Persons are not
required to respond to this collection of information unless it displays a currently valid OMB number and expiration date. Public reporting burden for this
collection of information, which is required for obtaining or retaining benefits (PL 105-220, Sec. 166), is estimated to average 26 hours per response, including
time for reviewing instructions, searching existing data sources, gathering and reviewing the collection of information. This is public information and there is no
expectation of confidentiality. The reason for the collection of information is general program oversight, evaluation and performance assessment. Send
comments regarding this burden, to the U.S. Department of Labor, Employment and Training Administration, Indian and Native American Programs, 200
Constitution Avenue, NW, Room S-4206, Washington, D.C. 20210.
ETA Form 9085

Revised July 2009
Previous forms not usable