9085 Summer Youth Report Form

INDIAN AND NATIVE AMERICAN YOUTH PROGRAM

OMB Control No: 1205-0422 Expires 09/ 30 / 2013

SECTION I - Grantee Identifying Information

Grantee Name and Address:

Grant Number:

___________________________________________________________________________________

Report End Date:

_______ / _______ / _________

Previous Period (A)

Current Period (B)

Program-to-Date (C)

SECTION II - Participation / Exiter Summary - [Enter participants who enrolled in the program and Exited during the program year.]

1. Total Participants

2. Total Exiters

3. Total Current Participants

SECTION III - Participant Characteristics Summary - [Enter characteristics of participants at enrollment]

Gender

4. Male

5. Female

Education

6. High School / Pre-High School Student

7. High School Graduate or Equivalent

8. Post High School Student

9. School Dropout

10. Pregnant and/or Parenting Youth

Barriers

11. Offender

12. Foster Child

13. Public Assistance Recipient

14. Basic Skills Deficiency

15. Individual With Disability

School Status

16. In-school youth

17. Out-of-school youth

Age

18. 14 - 18

19. 19 - 21

VETS

20. Eligible Veterans

21. Eligible Spouses

SECTION IV - Participant Goals and/or Attainments Summary - [Enter goals attained after receiving program services]

22. Completed Work Readiness

22. Completed Work Readiness

23. Completed Internship or Vocational Exploration Program

24. Completed Career Assesment

25. Entered Unsubsidized Employment (Including Military)

26. Remained in School

27. Returned to School Full Time

28. Enrolled in Job Corps

29. Improved Basic Skills by at Least Two Grade Levels

30. Attained High School Diploma

31. Attained GED

32. Completed Occupational Skills Training

33. Completed Leadership Skills Training

34. Entered Other (Non-Supplemental Youth) Training Program

Value

Numerator

Value

Numerator

Value

Numerator

SECTION V. Performance Outcomes / Performance

Denominator

Denominator

Denominator

35. Attainment of Two or More Goals (at least 60% of participants who exited the SYSP)

Certification: I Certify that to the best of my knowledge and belief that this report is correct and complete for the purpose set forth in the Grant Agreement.

Telephone Number:

Email:

Name of Grantee Certifying Official:

ETA Form 9085 (Rev. Sept. 2013)