HUD 40201 Youthbuild Reports

U.S. Department of Housing and Urban Development
Office of Community Planning and Development

Youthbuild Program Reports

Previous editions are obsolete

form HUD-40201 (7/97)

Youthbuild Program Reports

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

OMB Approval No. 2506-0142
(exp. 09/30/2003)

Public reporting burden for this collection of information is estimated to vary from 3 hours to 40 hours 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. This agency may
not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.
This information will be used by HUD to select grant recipients. Reports will be used to monitor and evaluate progress of grantees and programs. In accordance
with the HUD Reform Act, responses are required to obtain and maintain an award. The information furthers the proper performance of the functions of the
agency by allowing grant recipients to be selected in accordance with the authorizing legislation and HUD Reform Act. No confidentiality is promised,and the
information is not of a sensitive nature.

General Instructions
Purpose. There are two kinds of Youthbuild Program Reports. The
Semi-Annual Progress Report will provide HUD with information
on program progress and accomplishments for each Youthbuild
grant during the quarter reported. The Performance Evaluation
Report will allow HUD to assess the overall success of each
grantee’s program and report to Congress on the achievements of
the Youthbuild Program.
Authority. Specific authority for these reports is provided in Section
585.403 of the Youthbuild Final Rule (24 CFR Part 585).
Semi-Annual Progress Report. The Semi-Annual Progress Report must be submitted by all grantees. Grantees must make copies
of these reports as needed.
Part 5 Semi-Annual Progress Report is a summary of activities
undertaken.
Part 6 Statistical Summary summarizes information from the
Program Worksheets (see Parts 12 to 14 below) regarding the
program participants and units of housing completed.
Semi-Annual Progress Reports must be submitted to HUD on the
following schedule:
Period Activities Took Place
Due

Semi-Annual Progress Report

January 1 - June 30

July 31

July 1 - December 31

January 31

Please Note: Failure to submit Semi-Annual Progress Reports
by the deadline could result in a suspension of further grant
funds until the report is received.
Performance Evaluation Report. At the end of the 30 month grant
period, each grantee must submit a Performance Evaluation Report
to HUD. The Performance Evaluation Report has five components:

Part 7 Performance Evaluation Summary is a narrative that
summarizes the results of the grant.
Part 8 Statistical Summary (final report) summarizes information from the Program Worksheets (see Parts 12 to 14 below)
regarding the program participants and units of housing completed.
Part 9
grant.

Application Budget provides the approved budget for the

Part 10 Actual Costs reports the final program expenditures.
Part 11 Sources of Funds reports the sources and amounts of
funds contributed to the Youthbuild program.
Program Worksheets. Use of these worksheets is mandatory,
and will help grantees complete their Performance Evaluation
Report Summaries. They are to be kept in the grantee’s records for
at least three years after closeout of the grant. They are not to be
submitted to HUD. There are three separate worksheets:
Part 12 Housing Property Worksheet reports on all housing
completed by Youthbuild participants during the grant period. One
worksheet is used to record all properties completed.
Part 13 Housing Resident Worksheet reports on residents (tenants, homeowners, or residents of transitional housing for the
homeless) that move into housing constructed or rehabilitated by
Youthbuild participants. One worksheet is completed for each
property completed; make additional copies as needed.
Part 14 Participant Tracking Worksheet reports on each Youthbuild participant. Use one worksheet for each participant; make
additional copies as needed.
Mailing Address. Mail two copies of the completed report to:
Youthbuild Program
Department of Housing and Urban Development
451 - 7th Street SW, Room 7136
Washington, DC 20410
Mail one copy of the completed report to the CPD Field Office serving
your jurisdiction. (list of offices is attached)
Forms sent by FAX will not be accepted.

Previous editions are obsolete

form HUD-40201 (7/97)

Youthbuild Program Reports
Part 5
Semi-Annual Progress Report

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

Name and address of Grantee

Name of Contact Person

Grant Number

Telephone Number of Contact Person
(

)

Period Covered

I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate.
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)
Signature of authorized representative of grantee:
Date signed:
X

On separate sheets of paper attached to this page, not to exceed 10 pages, please submit complete and concise
narrative summaries on the following items:
A. Progress made during the reporting period in meeting Youthbuild program goals and objectives.
B. Activities accomplished during the reporting period, including important events and milestones.
C. Your biggest challenge during the reporting period and your response to the challenge.
D. Proposed changes, if any, in program design. (Note: For major changes or costs adjustments of more than
10 percent of any Youthbuild budget line item, you must request approval from HUD.)
E. Impediments encountered during the reporting period and solutions adopted to overcome them, as well as
any delays in progress of grant activities because of those impediments.
F. Unusual activities, accomplishments, and features of the grant or experiences that would be helpful for other
Youthbuild grantees.
G. Your dropout rate: what contributes to it and what is your program doing to address this problem?
Attach the following to the end of this report:
Part 6 Statistical Summary

Previous editions are obsolete

form HUD-40201 (7/97)

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

Youthbuild Program Reports
Part 6
Semi-Annual Progress Report
Statistical Summary
Project Name

_____________________________________________________

Contact Person _____________________________________________________
Activity
1. Original Grant Proposal
Proposed number of participants

Grant Number

________________________

Phone Number ________________________
This reporting period

Total to date for program

Proposed number of graduates
Proposed units of housing
2. Number of Participants
Total number of participants selected
Total number of participants who dropped out before completing the program
Total number of participants who have graduated
Total number of active participants
Dropout rate (# of dropouts/ # total selected participants)
Number who obtained either GED or diploma
3. Post-Graduation Activities
Number placed in jobs after graduation
Number enrolling in higher education after graduation
Number enrolling in job training program after graduation
4. Gender of Active Participants
Gender

Number

Percent of
Total Participants

Male
Female
5. Units of Housing
New Const.

Rehab

Number of Units:

RR

TH

HO

Total

Finished to date
Finished this period
In progress
Key: RR = Residential Rental

TH = Transitional Housing

HO = Homeownership

6. Expenditures
Period

Amount of money drawn down
from Youthbuild account

In reporting period
In total (to date)

Previous editions are obsolete

form HUD-40201 (7/97)

Youthbuild Program Reports
Part 7
Performance Evaluation Report
(Final Report)

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

Name and address of Grantee

Name of Contact Person

Grant Number

Telephone Number of Contact Person
(

)

Period Covered

I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate.
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)
Signature of authorized representative of grantee:
Date signed:
X

Performance Evaluation Summary
On separate sheets of paper attached to this page, not to exceed 20 pages, please describe the following:
A. Your accomplishments in meeting program goals and objectives.
B. Your accomplishments in meeting your participant attendance and retention level goals.
C. Academic achievements in post-secondary educational programs.
D. Your success in job placement efforts and housing completion.
E. Impediments encountered and solutions adopted to overcome them, as well as any delays in progress of grant
activities because of those impediments.
F. Unusual activities, accomplishments, and features of the grant or experiences that would be helpful for other
Youthbuild grantees.
Attach the following to the end of this report:
Part 8 Statistical Summary
Part 9 Application Budget
Part 10

Actual Costs

Part 11

Sources of Funds

Previous editions are obsolete

form HUD-40201 (7/97)

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

Youthbuild Program Reports
Part 8
Performance Evaluation Report
Statistical Summary
(Final Report)
Project Name

_____________________________________________________

Contact Person _____________________________________________________
Activity
1. Original Grant Proposal
Proposed number of participants

Grant Number

________________________

Phone Number ________________________
This reporting period

Total to date for program

Proposed number of graduates
Proposed units of housing
2. Number of Participants
Total number of participants selected
Total number of participants who dropped out before completing the program
Total number of participants who have graduated
Total number of active participants
Dropout rate (# of dropouts/ # total selected participants)
Number who obtained either GED or diploma
3. Post-Graduation Activities
Number placed in jobs after graduation
Number enrolling in higher education after graduation
Number enrolling in job training program after graduation
4. Gender of Active Participants
Gender

Number

Percent of
Total Participants

Male
Female
5. Units of Housing
New Const.

Rehab

Number of Units:

RR

TH

HO

Total

Finished to date
Finished this period
In progress
Key: RR = Residential Rental

TH = Transitional Housing

HO = Homeownership

6. Expenditures
Period

Amount of money drawn down
from Youthbuild account

In reporting period
In total (to date)

Previous editions are obsolete

form HUD-40201 (7/97)

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

Youthbuild Program Reports
Part 9
Application Budget
(Final Report)

Enter the approved budget amount by line item. If those budget items have not changed from your original application, you may submit a
copy of Exhibit 4B1 from that application.
Planned Sources and Uses
Grant Activities
Uses of Funds

Youthbuild

Other Federal

Sources of Funds
State

Local

Private

Total

$

$

$

$

$

$

$

$

$

$

$

$

1. Acquisition

2. Architecture and Engineering

3. Housing construction

4. Housing rehabilitation

5. Replacement Reserves, Operating Expenses, and Contingency
6. Legal fees, relocation, and
construction management
7. Outreach and Recruitment
Activities
8. Education and job training
(includes on-site training)
9. Trainee wage and need-based
stipends/benefits/incentives
10. Counseling, support services,
and development of employment
and leadership skills
11. Staff training and technical
assistance
12. Job placement and follow-up

13. Subtotal (sum of lines 1 through 12)
14. Administrative costs not included
above. Should not exceed 15%
of Youthbuild subtotal (line 13)
15. Total Costs
(sum of lines 13 and 14)

Note: Include only those items for which a cash payment will be made. Do not include the value of any in-kind contributions.

Previous editions are obsolete

form HUD-40201 (7/97)

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

Youthbuild Program Reports
Part 10
Actual Costs
(Final Report)
Enter the amounts actually spent for your Program.

Actual Sources and Uses
Grant Activities
Uses of Funds

Youthbuild

Other Federal

Sources of Funds
State

Local

Private

Total

$

$

$

$

$

$

$

$

$

$

$

$

1. Acquisition

2. Architecture and Engineering

3. Housing construction

4. Housing rehabilitation

5. Replacement Reserves, Operating Expenses, and Contingency
6. Legal fees, relocation, and
construction management
7. Outreach and Recruitment
Activities
8. Education and job training
(includes on-site training)
9. Trainee wage and need-based
stipends/benefits/incentives
10. Counseling, support services,
and development of employment
and leadership skills
11. Staff training and technical
assistance
12. Job placement and follow-up

13. Subtotal (sum of lines 1 through 12)
14. Administrative costs not included
above. Should not exceed 15%
of Youthbuild subtotal (line 13)
15. Total Costs
(sum of lines 13 and 14)

Note: Include only those items for which a cash payment was made. Do not include the value of any in-kind contributions.

Previous editions are obsolete

form HUD-40201 (7/97)

Youthbuild Program Reports
Part 11
Sources of Funds
(Final Report)

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

Enter the source and amounts of funds, other than Youthbuild, contributed to the Youthbuild program.
Name of Source
(A)

Type of Source
(B)

Amount of Funds
(C)

Program Use
(D)

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Column A: Identify the program, organization, or financial institution providing the funds for all components.
Column B: Identify the type of source (Federal, State, local government or private entity) providing funds for these
components of your Youthbuild Program.
Column C: Identify the amount of funds provided. This column should be consistent with Part 10 Budget amounts.
Column D: Indicate what these funds were used for in your program. This column should be consistent with Part 10.

Previous editions are obsolete

form HUD-40201 (7/97)

(7)

Previous editions are obsolete

(6) New or Rehab. Enter “N” for new construction or “R”
for rehabilitation of an existing property.

(5) Type. Enter the type of property as follows: “R” for
rental properties; “T” for Transitional or other homeless
properties; or “O” for Homeownership properties.

A
F
H
I
L
M
P
R
S
T
V

=
=
=
=
=
=
=
=
=
=
=

FmHA (Agriculture Dept)
FHA (HUD)
HOME (HUD)
IHA
Local
McKinney Act or Other Homeless
PHA
RTC
State
Private
Veterans Administration (VA)

Source. Enter one of the following codes:

1
2
3
Y
O

Hours
9

Units
8

Source
7

HOPE I (HUD)
HOPE 2 (HUD)
HOPE 3 (HUD)
Youthbuild (HUD)
Other, (please describe)

New
or Rehab
6

form HUD-40201 (7/97)

(9) Hours. Enter the number of hours that Youthbuild
participants worked on the property.

(8) Units. Enter the number of residential living units
contained in the property.

=
=
=
=
=

5

4

3

2

1

(1)- (4) Address, City, State, Zip Code. Enter the full
address of the housing properties where Youthbuild work
took place.

Instructions

Type

Zip Code

State

City

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

Property Address (street)

Youthbuild Program Reports
Part 12
Housing Property Worksheet

Previous editions are obsolete

Read the Instructions on the back before completing this report.
Unit Number
Number of
Type
Previously
Bedrooms
Homeless
1
2
3
4

Characteristics of Property and Occupants:

Property Street Address

Youthbuild Program Reports
Part 13
Housing Resident Worksheet

5

Total Rent

City

Income Data
Monthly Gross
Percent of
Income
Area Median
6
7

State

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

Race of Head
of Household
8

form HUD-40201 (7/97)

Rental
Assistance
11

Number of Units

Household Data
Size of
Type of
Household
Household
9
10

Zip Code

(2) Black, not Hispanic Origin. A person having origins in any of the black racial groups
of Africa, but not of Hispanic origin.

Total Number of Units. Enter the total number of residential units for the property.

Previous editions are obsolete

(5) Above 80% of the area median means a household whose adjusted income exceeds
80% of the median family income for the area, as determined by HUD with adjustments for
smaller and larger families.

(4) 61 - 80 Percent of Area Median means a household whose adjusted income exceeds
61% and does not exceed 80% of the median family income for the area, as determined
by HUD with adjustments for smaller and larger families.

(3) 51 - 60 Percent of Area Median means a household whose adjusted income exceeds
51% and does not exceed 60% of the median family income for the area, as determined
by HUD with adjustments for smaller and larger families.

(2) 31 - 50 Percent of Area Median means a household whose adjusted income exceeds
30% and does not exceed 50% of the median family income for the area, as determined
by HUD with adjustments for smaller and larger families.

(1) 0 - 30 Percent of Area Median means a household whose adjusted income is at or
below 30% of the median family income for the area, as determined by HUD with
adjustments for smaller and larger families.

7. Percent of Median Income. Enter one number based on the following definitions:

6. Monthly Gross Income. Enter the monthly gross household income.

5. Total Rent. Enter the total of the Tenant’s monthly rent including any rental assistance
such as Section 8.

4. Previously Homeless. Enter "Yes" if the occupant was previously homeless.

3. Type. Enter "T" for Transitional; "O" for Homeownership; or "R" for Residential rental.

2. Number of Bedrooms. Enter the number of bedrooms.
If the unit is an Efficiency, enter "0".

1. Unit Number. Enter the unit number, if applicable, for the unit.

(4) Tenant receives no assistance.

(3) Tenant receives other assistance.

(2) Tenant receives HOME Tenant-Based Assistance.

(1) Tenant receives Section 8 assistance.

form HUD-40201 (7/97)

11. Rental Assistance. Use the key presented below the table. Enter one number based
on the following definitions:

(5) Other. Any household that is not included in the above 4 definitions, including two
or more unrelated individuals.

(4) Related/Two Parents. A two parent household with dependent (18 or under)
children.

(3) Related/Single Parent. A single parent household with dependent minor (18 or
under) children.

(2) Elderly. One or two person households containing a person at least 62 years of age.

(1) Single/Non-Elderly. One person household in which the person is not elderly.

10. Type of Household. Enter one number based on the following definitions:

9. Size of Household. Enter the number of persons in the household.

(5) Hispanic. A person of Mexican, Puerto Rican, Cuban, Central or South American
or other Spanish culture or origin, regardless of race.

(4) Asian or Pacific Islander. A person having origins in any of the peoples of the Far
East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes,
for example, China, India, Japan, Korea, the Philippines Islands, and Samoa.

(3) Native American. A person having origins in any of the original peoples of the North
American Continent, and who maintains cultural identification through tribal affiliations or
community recognition.

(1) White, not Hispanic Origin. A person having origins in any of the original peoples
of Europe, North America, or the Middle East, but not of Hispanic origin.

Address, City, State and Zip Code. Enter the full address of the property where
Youthbuild on-site training and work took place.

Characteristics of Property and Occupants. Provide a brief description of the property
as well as any occupants. Complete items 1 - 11 for each residential unit contained in the
property.

8. Race of Head of Household. Use the key presented below the table. Enter one
number only based on the following definitions:

This form must be completed on all Youthbuild properties completed and occupied during
the 30 month grant period. Retain this worksheet for your files.

Instructions for Completing Part 13
Housing Resident Worksheet

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

Youthbuild Program Reports
Part 14
Participant Tracking Worksheet

Sensitive Information: The information collected on this form is considered sensitive and is protected by the Privacy Act. The Privacy Act requires that these records
be maintained with appropriate administrative, technical, and physical safeguards to ensure their security and confidentiality. In addition, these records should be
protected against any anticipated threats to ,their security or integrity which could result in substantial harm, embarrassment, inconvenience, or unfairness to any
individual on whom the information is maintained.

Section I: Entrance Report (Complete this section when the participant enters the program.)
1. Participant Identification(Last Name)

(First Name)

2. Social Security Number

(Middle Initial)

3. Date of Birth (MM/DD/YY)

4. Date of Program Entry (MM/DD/YY)

5. Current Address: Street/City/State/Zip

6. Gender:

a. Male

a. White (Not Hispanic)

7. Race/Ethnicity:

b. Female

c. Hispanic

d. American Indian or Alaskan Native (Not Hispanic)

8. Highest Grade or Year of School Completed:

9. Current Living Status:

b. Black (Not Hispanic)

a. Less than 8

b. 8th Grade

e. 11th Grade

f. High School graduate/GED

a. Living with Family

d. Living in a Homeless Shelter

e. Asian/Pacific Islander

b. Living alone

c. 9th Grade

d. 10th Grade

c. Living with Friends

e. Living in a Halfway House

f. Living in a Work/Release Program

g. Other:(specify) ______________________________________________________________________________________________________
10. Current Employment Status:

a. Employed, Full-Time

b. Employed, Part-time

c. Unemployed

11. If employed, current hourly wage rate: 12. If employed, number of hours, on average, working during a week: 13. Total Family Income from all sources:
$
______________ Hours
$
14. Source of Referral to this Youthbuild Program:(Check all that apply)

a. Local JTPA Program

c. Apprenticeship Program(specify) ________________________
e. Education Institution

f. Local Housing Authority

d. Local Trade Union(specify) _____________________________
g. State/local training program

15. How did the participant learn about the Youthbuild Program? (Check all that apply)
d. Neighborhood Flyers or Newspaper

b. Local JOBS Program

e. Shelter

a. Friends

h. Other(specify) ________________
b. TV/Radio

f. Parole Officer

c. City-wide Newspaper
g. Neighbors

h. Other:(specify)

Section II: Participation Report
16. Educational and Support Services
(a)
(b)
(c)
(d)
(e)

Remedial/Basic Skills
Bi-Lingual Skills
High School/GED Courses
Post Secondary Assistance
Vocational Skills

Number of courses completed
or services used
_____________________
_____________________
_____________________
_____________________
_____________________

Educational and Support Services
(f)
(g)
(h)
(i)
(j)

Other Support Services
Counseling
Leadership Skills
Job Interview Skills
Job Placement Skills

17.

Total number of hours and percent time spent by the participant on education and support services:
Hours:____________________
Percent educational hours to total program hours:___________________

18.

Number of hours spent on construction work-site by the participant:
Hours:_____________________
Percent construction hours to total program hours:___________________

19.

Total amount of hourly work-site wages paid to the participant:
Total amount of need-based stipends, if any, paid to the participant:

Previous editions are obsolete

Number of courses completed
or services used
_____________________
_____________________
_____________________
_____________________
_____________________

$_________________________
$_________________________
form HUD-40201 (7/97)

Section III: Exit Report (Complete this Section only when a participant completes or leaves the program.)
20. Date of program exit:

21. Number of months in the Program:

22. Overall level of participation in the program:
c. Low, participated in few functions
23. Reason for Exit:

a. High, participated in most functions

b. Medium, participated in some functions

a. Successfully completed program
b. Left Voluntarily

Reason left the program without completion:

c. Asked to leave the program

d. Left because Essential Service was unavailable:(specify) ___________________________________________________________________
e. Other:(specify) _____________________________________________________________________________________________________
24. Highest Grade or Year of School completed when leaving program:
c. Trade School or Vocational School
25. Current Employment Status:

a. Less than 12

b. High School Graduate/GED

d. Some College

a. Employed, Full-time

26. If employed, current hourly Wage Rate:

b. Employed, Part-time

c. Unemployed

$ ______________

Number of hours, on average, working within a week:

_______________

27. If employed, list the broad industry occupational title:
a. Construction Laborer

b. Skilled Construction Trade

c. Construction Management

d. Property Maintenance

e. Other (specify actual job title): __________________________________________________________

28. If currently unemployed, the reason why:
a. Continuing Education

b. Entered Apprenticeship Program

e. Lack of Transportation

f. Other, specify: _______________________________________________________________________

Previous editions are obsolete

c. Health

d. Family

form HUD-40201 (7/97)

Instructions for Completing Youthbuild Participant Tracking Worksheet, Part 14
The Youthbuild Participant Tracking Worksheet, Part 14 must be
kept in your files. Section I (Entrance Report) is completed for each
participant entering the program. Section II (Participation Report)
provides a record of the services and training received by each
participant. Section III (Exit Report) is completed when participants
complete or leave the program for whatever reason. In all cases, the
full name and Social Security Number of each participant must be
provided in Section I to track the status of the participant.

Section II: Participation Report

Section I: Entrance Report (Complete this section when a
participant enters the program.)

Description of Educational and Support Services:

1. Participant Identification: Enter the last name, first name, and
middle initial of the person participating in the Youthbuild Program.
2.

Social Security Number: Enter the SSN of the participant.

3. Date of Birth: Using the MM/DD/YY format, enter the date of
birth of the participant.
4. Date of Program Entry: Using the MM/DD/YY format, enter the
date the participant entered the Youthbuild Program.
5. Current Address: List the current address for the Youthbuild
participant including the street address, city, State, and zip code.
6. Gender: Check the appropriate code to indicate whether the
participant is male or female.
7. Race/Ethnicity: Check the appropriate code indicating the
racial/ethnic background of the participant.
8. Highest Grade or Year of School Completed: Check the
appropriate code indicating the highest grade or year of school
completed by the participant upon entry into the program.
9. Current Living Status: Check the appropriate code indicating
the participant’s current living arrangements.
10. Current Employment Status: Check the appropriate code
indicating whether the participant was currently employed, full/parttime, or unemployed upon entry into the program.
11. Current Hourly Wage Rate: If the participant was employed
upon entry into the program, please list the hourly wage rate he/she
was receiving. If not working, please leave blank.
12. How many hours worked: If the participant was employed upon
entry into the program, please list his/her average number of hours
worked within a week in the current job. If the participant was not
working, please leave blank.
13. Total Family Income: Please enter the total family income for
the participant. Total family income includes income received by all
members of the family and includes incomes from all sources
including wages/salaries, public assistance, Social Security and
pensions.
14. Source of Referral to the Program: If the participant entered the
program through a formal referral, please check the appropriate
code indicating the source of the referral.
15. How did the participant learn about Youthbuild? Please check
the appropriate code to indicate how the participant found out about
the program.

This section is to be completed for each participant after program
entry.
16. Educational and Support Services: The table includes a listing
of 10 different services and blank column to be completed to show
the number of courses the participant completed or the services
used.

(a) Remedial/Basic Skills: These programs include all basic
education instruction in math, reading, and other functional skills not
aimed at a high school diploma or GED. Specific types of programs
which should be considered in this category are basic literacy
programs or Adult Basic Education (ABE) programs for adults with
less than an 8th grade education.
(b) Bi-Lingual Skills: These programs include all basic educational instruction in basic education and other functional skills such
as English for Speakers of Other Languages (ESOL) or English as
a Second Language (ESL) which can be aimed at a high school
diploma or GED.
(c) High School/GED Courses: Adult secondary education
programs, such as adult high schools (where those completing the
program receive a high school diploma) or General Education
Development (GED) classes administered by school districts and
community-based organizations (aimed at receiving a high school
equivalency certificate).
(d) Post Secondary Assistance: Programs for high school
graduates or participants with a GED to improve employability but
not having a direct vocational or training emphasis. Courses at a
community, junior, or four-year college leading to a degree or
general academic advancement are examples.
(e) Vocational Skills: Technical training in a vocational or trade
school, vocational program of a community or junior college, or
work-site-based training. These programs are clearly targeted to
qualifying for a specific job (such as auto mechanics, heating/air
conditioning repair) and may involve a certificate or similar credential
(such as a licensed practical nurse).
(f) Other Support Services: Other programs and services for
participants with or without a GED to improve employability as well
as family life, health, self esteem, etc. Course to obtain a valid
driver’s license, or to improve familial communications are examples.
(g) Counseling: This may include a wide range of counseling
services including drug and alcohol abuse, counseling in the areas
of personal development, stress management, parenting and child
development, counseling in homemaking, household management,
and money management.
(h) Leadership Skills: This may include any services to enhance or create leadership skills for the participant such as training
focusing on group skills, group dynamics, group motivation, etc.
(i) Job Interview Skills: This may include a wide range of
services focused on job interview techniques and skills to enhance
the participant’s employability.
(j)

Previous editions are obsolete

Job Placement Skills: This may include a wide range of

form HUD-40201 (7/97)

services focused on how to look for jobs, where to go to get
information on available jobs, how to approach employers about job
opportunities etc. to enhance the participant’s employability.
17. Calculate the total number of hours spent by the participant
attending educational courses and using Youthbuild support services. Calculate the percent time spent on educational and support
services activities as compared to total program time spent by the
participant.
18. Calculate the total number of hours spents on the construction
work-site by the participant. Calculate the percent time spent on
construction on-the-job training at the work site as compared to total
program time spent by the participant.
19. Calculate the total amount of wages paid to the participant for
work conducted at the construction site. Calculate the total amount
of need-based stipends and/or incentives, if any, paid to the participant. If none, please leave blank.
Section III. Exit Report (Complete this section when a participant
completes or leaves the program)
20. Enter the date that the participant exited the Youthbuild Program.
21. Number of Months in the Program: Calculate the number of
months the participant was in the program using Date of Program
Entry (4) in Section I and the Date of Program Exit (20) above.
22. Overall Level of Participation in the Program: Rate the overall
level of participation exhibited by the participant in the program using
“high” for extremely active participation in most functions; “medium”
for average participation in some functions; and “low” for less than
average participation.
23. Reason for Exit: There are two basic reasons for a participant
exiting the program: (1) He/she completed the program or (2) He/
she left the program before completing the obligations of the
program. Check only one of the codes to indicate the reason for
exit.

Previous editions are obsolete

(a) Successfully completed program is checked when the
participant has completed all his/her obligations under the program.
(b) Left Voluntarily means the participant was terminated
through mutual consent of the participant and the program, or by the
participant’s decision to withdraw.
(c) Asked to Leave the Program means the program terminated the participant because the participant failed to meet required
program obligations or the participant’s actions were inconsistent
with the purpose of the program.
(d) Left because Essential Service was Unavailable means the
program was unable to provide a particular service deemed essential to the participant’s ability to successfully complete the program.
Specify the unavailable service(s).
(e) Other: Specify any other reasons why the participant left
the program without completion.
24. Highest Grade of School Completed: Check the appropriate
code indicating the highest grade of school completed by the
participant upon exit from the program.
25. Current Employment Status: Check the appropriate code to
indicate whether the participant is employed, full-time or part-time,
or unemployed upon exit from the program.
26. Current Hourly Wage Rate and Number of Hours Worked Per
Week: If the participant is employed upon exit from the program,
please enter the current hourly wage rate received by the participant
and the number of hours he/she works per week.
27. Industry/Occupational Category: If the participant is employed
upon exit from the program, please check the appropriate code
indicating the broad industry/occupational category in which the
participant is currently employed.
28. Reason Why Unemployed: If the participant is unemployed
upon exit from the program, please check the appropriate code
indicating the primary reason the participant is currently unemployed.

form HUD-40201 (7/97)