ETA 9133 Eligible Veterans and Transitioning Service Members Serv

ELIGIBLE VETERANS AND TRANSITIONING SERVICE MEMBERS SERVICES REPORT (ETA FORM 9133)

OMB No.:

1205-0469

Expires:

10/31/2011

A. GRANTEE IDENTIFYING INFORMATION

1. Grantee Name:

3. Workforce Programs

Wagner-Peyser Employment Service Jobs for Veterans State Grants-DVOP/LVER Programs

2. Grantee Mailing Address:

4. Cumulative 4-Quarter End Date:

_____________________________________________________________________________

mm/dd/yyyy

City ________________________________

State ______ Zip Code ___________

5. Report Due Date:

mm/dd/yyyy

B. CUSTOMER SUMMARY INFORMATION

Performance Items

A Totals (including non-veterans)

B Totals Veterans and Other Eligible Persons

C TSMs

D Campaign Veterans

E Disabled Veterans

F Special Disabled Veterans

G Recently Separated Veterans (3 Yrs)

H Female Veterans

I Homeless Veterans

1

2

3

4

Totals

18-44

45-54

55 and Over

1. Total Entrants

2. Total Participants

2a. Male

2b. Female

2c. 18-44

2d. 45-54

2e. 55 and Over

3. Received Staff-Assisted Services

3a. Attended TAP Employment Workshop

3b. Received Career Guidance

3c. Received Job Search Activities

3d. Referred to Employment

3e. Received Intensive Services

3f. Referred to Federal Training

3g. Placed in Federal Training

3h. Referred to Federal Job

3i. Referred to Federal Contractor Job

C. REPORT CERTIFICATION/ADDITIONAL COMMENTS

1. Report Comments/Narrative:

2. Name of Grantee Certifying Official/Title:

3. Telephone Number:

4. Email Address:

OMB Burden Statement: These reporting instructions have been approved under the Paperwork Reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a currently valid OMB number. Obligation to respond is required to obtain or retain benefits (Workforce Investment Act [Section 185(a)(2)] and Wagner-Peyser Act [29 USC 49i]). The 50 hour public reporting burden for this collection of information, which is to assist with planning and program management and to meet Congressional and statutory requirements, includes time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information. Send comments regarding this burden estimate, or any other aspect of this collection, including suggestions for reducing burden, to the U.S. Department of Labor, Employment and Training Administration, Office of Policy Development and Research, Room N-5641, 200 Constitution Avenue, NW, Washington, DC 20210.