Form ETA-9122 SCSEP Unsubsidized Employment Form

SCSEP Unsubsidized Employment Form
1. Name of participant___________________

OMB Approval Number: 1205-0040
Expiration Date: 04/30/2014

2. PID __________________________

Employer Information
3. Name of employer ______________________________________________________
4. Employer mailing address
____________________________________________________________________
a. Number and street, suite number; and/or PO Box

____________________________________________________________________
b. City

____________________________________________________________________
c. State

d. ZIP code

5. FEIN_____________________________
6. Employer type
Not-for-profit
Government
7. Is employer a host agency?

For-profit
Self-employment
Yes

No

8. Did employer provide an OJE training site for this participant?
No

Yes

9. Employment site name and location________________________________________
9a. *Employer received customer satisfaction survey in PY _________
9b. Employer continued availability

Available

Not available

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

Authorized for Local Reproduction

ETA-9122
(Revised January 2011; 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 Unsubsidized Employment Form

Contact/Supervisor Information
10. Name of contact person _________________________________________________
11. Contact person’s mailing address if different from number 4
__________________________________________________________________________________
a. Organization name or address field 1
__________________________________________________________________________________
b. Number and Street, Suite Number; and/or PO Box or address field 2
__________________________________________________________________________________
c. City
__________________________________________________________________________________
d. State
e. ZIP Code

12. Contact person’s title ___________________________________________________
12a. Contact person’s salutation

Mr.

Ms.

Dr.

13. Contact person’s phone number___________________________________________
13a. Contact person’s fax number ____________________________________________
13a1. Contact person’s cell phone number ______________________________________
13b. Contact person’s e-mail address __________________________________________
Complete fields 13c-13i if supervisor is different from contact person (number 10).
If supervisor is the same as contact person, skip to field 14.
13c. Name of supervisor ____________________________________________________
13d. Supervisor’s mailing address if different from number 4
_____________________________________________________________________
a. Organization or address field 1

_____________________________________________________________________
b. Number and Street, Suite Number; or PO Box or address field 2
_____________________________________________________________________
c. City

_____________________________________________________________________
d. State

e. ZIP Code

13e. Supervisor’s title ______________________________________________________
13f. Supervisor’s salutation

Mr.

Ms.

Dr.

13g. Supervisor’s phone number _____________________________________________
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SCSEP Unsubsidized Employment Form

13h. Supervisor’s fax number ________________________________________________
13h1. Supervisor’s cell phone number _________________________________________
13i. Supervisor’s e-mail address ______________________________________________
Placement Information
14. Start date_______________________ (MM/DD/YYYY)
15. End date_______________________ (MM/DD/YYYY)
16. Starting wage per hour $_____________________
17. Benefits (check all that apply)
a. Health insurance
b. Sick leave
c. Pension/profit sharing

d. Vacation
e. Transportation
f. Room and board

g. Other__________(specify)
h. None

18. At time of placement, is employment expected to be full- or part-time?
Full-time

Part-time

If part-time, number of hours per week expected _________
19. Job title ______________________________________________________________
19a. Participant’s job code _________
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

8. Food Preparation and Service
9. Healthcare
10. Legal
11. Maintenance and Custodial
12. Management

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

13. Office and Administrative
Support
14. Personal Care and Service

19b. High-growth placement
1. Automotive
2. Advanced Manufacturing
3. Biotechnology
4. Construction
5. Energy
20. Training-related placement?

6. Financial Services
7. Geospatial
8. Health Care
9. Hospitality
10. Information Technology
Yes

11. Retail
12. Transportation
13. None

No

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SCSEP Unsubsidized Employment Form
21. Was placement the result of a substantial service provided to the employer by the
sub-grantee?
Yes
No
22. Unsubsidized employment comments

Customer Service Survey Information
23. CS survey number 1 __________________ Date _____________ (MM/DD/YYYY)
24. CS survey number 2 __________________ Date _____________ (MM/DD/YYYY)
25. CS survey number 3 __________________ Date _____________ (MM/DD/YYYY)
Follow-up Information
26. *90-day date _______________________________ (MM/DD/YYYY)
27. Has the participant returned to program within the first 90 days after exit?
Yes
No
27a. Has the participant re-enrolled in SCSEP within the first 90 days after exit?
Yes
No
28. Follow-up 1
a. *Scheduled date____________________ (MM/DD/YYYY)
b. Completed date____________________ (MM/DD/YYYY)
c. Any wages for first quarter after exit quarter? Please also indicate method of
verification
i.
vi.
vii.
viii.

No wages
Yes, supplemental through case management, participant survey, and/or verification
with the employer
Unable to obtain information
Excluded

c1. If excluded, reason
i.
ii.
iii.
iv.

Deceased
Health/medical
Family care
Institutionalized

29. Follow-up 2
a. *Scheduled date _______________________________(MM/DD/YYYY)
b. Completed date ________________________________(MM/DD/YYYY)

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SCSEP Unsubsidized Employment Form

c. Any wages for second quarter after exit quarter? Please also indicate method of
verification
i.
vi.
vii.
viii.

No wages
Yes, supplemental through case management, participant survey, and/or verification
with the employer
Unable to obtain information
Excluded

c1. If excluded, reason
i.
ii.
iii.
iv.

Deceased
Health/medical
Family care
Institutionalized

d. If yes, earnings for second quarter after exit quarter $__________________
e. Any wages for third quarter after exit quarter? Please also indicate method of
verification
i.
vi.
vii.
viii.

No wages
Yes, supplemental through case management, participant survey, and/or verification
with the employer
Unable to obtain information
Excluded

e1. If excluded, reason
i.
ii.
iii.
iv.

Deceased
Health/medical
Family care
Institutionalized

f. If yes, earnings for third quarter after exit quarter $_______________
30. Follow-up 3
a. *Scheduled date____________________ (MM/DD/YYYY)
b. Completed date____________________ (MM/DD/YYYY)
c. Any wages for fourth quarter after exit quarter? Please also indicate method of
verification
i.
vi.
vii.
viii.

No wages
Yes, supplemental through case management, participant survey, and/or verification
with the employer
Unable to obtain information
Excluded

c1. If excluded, reason
i.
ii.
iii.
iv.

Deceased
Health/medical
Family care
Institutionalized

31. Customer satisfaction and follow-up comments.

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