Participant Tracking Data

APPENDIX B-1

Monthly Participant Tracking Form

(as part of Program Participation Forms)

Monthly Participant Tracking Form

Prefilled by Mathematica: Applicant’s Name: ______________________________________________________ First Name MI Last Name SET Participant Number: ___________________________________________ Assigned SET Provider: ________________________________________________ Date of Assignment to the SET Program: ­­­­­­­­­­­­­­­­­­­_________
To be filled by MDO staff: Date of Intake at MDO: _________ Intake conducted by: _________________________  Participant provided adequate proof of being a dislocated worker at intake meeting. Content of Intake Meeting: [Describe briefly (a) participant’s status in and/or readiness for establishing a business and (b) the service plan recommended.] ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Designated SET Advisor: ___________________________________________________ Participant’s enrollment in the SET program was terminated on: _________ (As relevant)
Contact date	Type of contact	Describe participant progress toward self-employment; obstacles encountered; adjustments to service plan. If no contact was made explain reason why.
1.	 In-person check-in  Phone check-in  Reassessment  Other: ______________  No contact
2.	 In-person check-in  Phone check-in  Reassessment  Other: ______________  No contact
3.	 In-person check-in  Phone check-in  Reassessment  Other: ______________  No contact
Types of services received since previous monthly report and total hours of service for each:  Training:_______________________ Hours  Other (describe: ________________) ___________ Hours  Technical Assistance: ____________ Hours  Other (describe: ________________) ___________ Hours  Peer support groups:_____________ Hours  Other (describe: ________________) ___________ Hours
Business Development Milestones. Please indicate which development milestones the participant has reached since the previous monthly report. (Check all that apply)  Comprehensive and satisfactory business plan on (Date: ___________________________________)  Comprehensive and satisfactory marketing plan on (Date: ___________________________________)  Business registration on (Date: ___________________________________)  Other [Please specify:________________________________________________________________________]

OMB Control No.: xxxx-xxxx, Expiration Date: xx/xx/20xx

Public Burden Statement

The SET Demonstration is being carried out under the legal authority of PL 105-220 (subtitle D [sections 171 and 172]). Completing this document, which seeks to help the U.S. Department of Labor understand the effects of SET services on customers’ employment-related outcomes, is required to obtain or receive the benefit of a reimbursement for service delivery. The public reporting burden for this collection of information is estimated to average 3 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 to the Office of Policy Development and Research, U.S. Department of Labor, Room N5641, 200 Constitution Avenue, NW, Washington, DC 20210.

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