Form ETA-9123 SPARQ Exit Form

SCSEP Exit Form

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

Exit Information
1. Name of participant ____________________ 2. PID _____________________________
3. Participant mailing address (if changed)
__________________________________________________________________________
a. Number and Street, Apt. Number; or PO Box

__________________________________________________________________________
b. City

c. County

__________________________________________________________________________
d. State
e. ZIP Code
4. Phone number of participant (if changed) _________________________________________
5. Exit due to unsubsidized placement? (Select one only)
i. Yes, regular employment
ii. Yes, self-employment

iii. No

6. If exit is not due to unsubsidized employment, other reason for exit (Select one only)
i. Moved from area
ii. For cause
iii. Voluntary
iv. Non-income eligible
v. Durational limit
vii. Deceased
viii. Health/medical
ix. Family care
x. Institutionalized
6a. Non-exit reasons for closing the record (Select one only)
i. Withdrew application prior to assignment
ii. *Transferred to another project (specify grantee code) __________
iii. *Moved to another sub-grantee (specify sub-grantee code) __________
iv. Dual enrollment
7. Date of exit or other closing of record _________________ (MM/DD/YYYY)
7a. Will participant engage in volunteer work after participation?
Yes
No
Unknown
If yes, number of volunteer activities_____________

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

Authorized for Local Reproduction

ETA-9123
(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 six (6) 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).

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SCSEP Exit Form

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

Waiver of Confidentiality
I, _________________________________, hereby authorize __________________________________
[name of participant]

[name of employer]

to release to ___________________________________ information regarding my employment status
[name of sub-grantee]

and wages for a period of thirteen months from the date below. This information may be used solely
for statistical purposes and may not be disclosed to anyone not connected with the Senior Community
Service Employment Program (SCSEP) in a manner that is individually identifying.

8. Signature of participant ___________________________
9. Date of signing _____________ (MM/DD/YYYY)

9a. Exclusion discovered after exit (only for exiters not in unsubsidized employment)
i. Deceased
ii. Health/medical
iii. Family care
iv. Institutionalized
9b. Date exclusion occurred _____________ (MM/DD/YYYY)
10. Exit comments

Volunteer Information
11. Name of primary volunteer activity_________________________________
12. Activity conducted in:
Government organization

Not-for-profit organization
Informal; no organization

13. Is this activity conducted in a SCSEP host agency?

Faith-based organization

Yes

No

14. Number of hours per quarter participant expects to volunteer in this activity________
15. Total number of volunteer activities_____________
16. Follow-up
a. *Scheduled date____________________ (MM/DD/YYYY)
b. Completed date____________________(MM/DD/YYYY)
c. Engaged in volunteer work?
Yes
No
*No data entry in SPARQ. Field is system-generated.

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