Form ETA 9120 ETA 9120 SPARQ Participant Form

SCSEP Participant Form

OMB Approval Number: 1205-0040
Expiration Date: 4/30/2014

Participant Information
1. Last name ______________________

2. First name_________________________

3. Middle initial __________

4. Social Security # ___________________

4a. Participant ID ____________

5. Home phone (____) ________________

5a. Cell phone (____) ________________
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
c. TANF
Assistance)
e. Suppl. Nutrition Assistance (SNAP)
g. Social Security Disability (SSDI)
(specify)______________________
Authorized for Local Reproduction

b. Supplemental Security Income (SSI)
d. State or local welfare (General
f. Subsidized housing
h. Other
ETA-9120
(Revised February 2012; replaces prior versions)

This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0040. 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 required to obtain or retain benefits (PL 109-365 Sec 501-518) 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. Send comments regarding this burden estimate or any other
aspect of this collection, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Adult Services,
Room S-4203, 200 Constitution Avenue, NW, Washington, DC 20210 (PRA Project 1205-0040).

13. Employed prior to participation?
i. Employed
ii. Employed, but with notice of termination

iii. Not employed

13a. Did applicant engage in volunteer work prior to participation?
If yes, total number of volunteer activities________________

Yes

No

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
c. Black, African American
e. White

b. Asian
d. Native Hawaiian/Pacific Islander
f. Did not voluntarily report

21. Education ________ last grade completed (Select one code from following list)
00=no grade school
1-11 years of school
A11=completed 12 years of
school but no HS diploma
12=HS diploma

88=GED or certificate of equivalency for HS
13-15 years of school completed (1-3 years of college)
16=BA/BS or equivalent
17=education beyond a bachelor's degree

22. Limited English Proficiency (LEP)

Yes

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

No

18=master's degree
19=doctoral degree
21=vocational/technical
degree
22=associate's degree

23. If LEP, please specify primary language _____ (Select one code from following list)
10. Amharic
11. Arabic
12. Armenian
13. Bosnian
14. Cantonese (Yue)
15. French
16. French Creole
17. German
18. Greek
19. Gujarathi

20. Hebrew
21. Hindi
22. Miao (Hmong)
23. Italian
24. Hungarian
25. Ilocano
26. Japanese
27. Korean
28. Laotian
29. Mandarin

24. Low literacy skills?

30. Mon-Khmer (Cambodian)
31. Navajo
32. Persian (including Dari)
33. Polish
34. Portuguese
35. Punjabi
36. Russian
37. Samoan
38. Serbo-Croatian
39. Somali

Yes

40. Spanish
41. Tagalog
42. Thai
43. Urdu
44. Vietnamese
45. Yiddish
46. Other_____
____________

No

25. Veteran (or eligible spouse of veteran)?
a. Veteran

b. Eligible spouse of veteran

26. Disability?
Yes, self-report
Yes, documentation

c. Non-covered person

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________
1. Art, Design, Entertainment,
Sports, and Media
2. Business and Financial
Operations
3. Community and Social Services
4. Computer and Mathematical
5. Construction, Installation, and
Repair
6. Education, Training, and Library
7. Farming, Fishing, and Forestry

2 ________

3________

8. Food Preparation and Service
9. Healthcare
10. Legal
11. Maintenance and Custodial
12. Management
13. Office and Administrative
Support
14. Personal Care and Service

41. Enrollment comments

42. Signature of director or authorized representative
____________________________________________
43. Date of eligibility determination
__________________________(MM/DD/YYYY)

15. Production, Assembly, Light
Industrial
16. Protective Service
17. Retail, Sales, and Related
18. Self-Employment
19. Transportation and Material
Moving

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)

7

Waiver of Durational Limit
51. Severe disability?
Yes
No
51a. Date of last update ______________________ (MM/DD/YYYY)
52. Frail?
Yes
No
52a. Date of last update ______________________ (MM/DD/YYYY)
53. Old enough for but not receiving SS Title II?
Yes
53a. Date of last update ______________________ (MM/DD/YYYY)

No

54. Severely limited employment prospects in area of persistent unemployment?
Yes
No
54a. Date of last update ______________________ (MM/DD/YYYY)
55. Limited English Proficiency (LEP)?
Yes No
55a. Date of last update ______________________ (MM/DD/YYYY)
56. Low literacy skills?
Yes
No
56a. Date of last update ______________________ (MM/DD/YYYY)
*57. 75 or over?

Yes

No

60. Recertification/waiver comments

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

8