Eta-9085 Indian And Native American Youth Program Annual / Semi-a

INDIAN AND NATIVE AMERICAN YOUTH
PROGRAM ANNUAL / SEMI-ANNUAL REPORT
OMB No. 1205-0422
Expires: 01/31/2020

SECTION I - Grantee Identifying Information
Grantee Name and Address:

Grant Number:
Report End Date:

Previous Period
(A)

Current Period
(B)

SECTION II - Participant / Exiter Summary - [Enter participants who enrolled in the program and exited during the program year.]
1. Total Participants
a. Participation in Summer Employment
2. Total Exiters
a. Summer Employment Exiters
3. Total Current Participants
SECTION III - Participant Characteristics Summary - [Enter characteristics of participants at enrollment.]
4. Male
5. Female
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
11. Offender
12. Foster Child
13. Public Assistance Recipient
14. Basic Skills Deficiency
15. Individual With Disability
16. In-school youth
17. Out-of-school youth
18. 14 - 18
19. 19 - 21
20. 22 - 24 (Recovery Act Participants Only)
21. Eligible Veterans

Program to Date
(C)

SECTION IV - Participant Goals and/or Attainments Summary - [Enter goals attained after receiving program services.]
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
35. Successful Completion of Summer Employment
Previous Period
(A)
Performance Items
Value

Numerator
Denominator

Current Period
(B)
Value

Program-to-Date
(C)

Numerator

Value

Denominator

Numerator
Denominator

SECTION V - Performance Outcomes / Performance
36. Attainment of Two or More Goals

37. Educational Attainment for Dropouts

Remarks:

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.
Grantee Name:
Phone No:

Email:

Certifying Official:

This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0422. Persons are not required to respond to this collection of information unless it displays a currently
valid OMB number and expiration date. Public reporting burden for this collection of information, which is required for obtaining or retaining benefits (PL 105-220, Sec. 166), is estimated to average 2 hours per
response, including time for reviewing instructions, searching existing data sources, gathering and reviewing the collection of information. The reason for the collection of information is general program oversight,
evaluation and performance assessment. Send comments regarding this burden to the U.S. Department of Labor, Employment and Training Administration, Indian and Native Americans Program, 200 Constitution
Avenue, NW, Room N4209, Washington, D.C. 20210.

ETA Form 9085 (September 2019)

OMB Control Number 1205-0422
Expiration Date: 01/31/2019
Revised September 2019

Workforce Innovation and Opportunity Act,
Section 166, Indian and Native American Programs
Reporting Instructions for the Supplemental Youth Services (SYS) Program
Report (ETA Form 9085)
Workforce Investment Act (WIA) section 166 grantees are required to submit performance reports to the United
States Department of Labor, Employment and Training Administration (USDOL/ETA) to comply with the
record keeping and reporting requirements of the Supplemental Youth Services (SYS) Program grant. The SYS
report provides information on current program participants, including important socio-economic
characteristics, participants who have exited the program, and performance outcomes for the most recent semiannual period and cumulated for the most recent program year (April 1 – March 31). The information
contained on this report will be used to determine the levels of participation, services received, and
accomplishments for each SYS program grant.
Information contained on ETA Form 9085 must be submitted directly to ETA’s Enterprise Business Support
System (EBSS) (formerly called the Enterprise Information Management System (EIMS)).

Section I. Grantee Identifying Information
Grantee Name and Address – Enter the grantee name as it appears on the appropriate Notice of Obligation
(NOO) or equivalent official document from the U.S. Department of Labor and the physical address of the
grantee headquarters.
Grant Number – The grant number will is pre-populated and will reflect the grant number for the program year
for which the data pertains to. For example, if the report end date is 09/30/2019, the participant information
will be for the period, April 1, 2019 to September 30, 2019 which is in program year (PY) 2019. Therefore the
grant number assigned to PY 2019 will be pre-populated on the form.
Report End Date – The report end date will be pre-populated with the last month, day, and year (mm/dd/yyyy)
of the semi-annual period on which the report is being prepared. For example, if the report is being prepared
for the semi-annual period ending September 30, 2019, the Report End Date, this field will reflect 09/30/2019.

Section II. Participant / Exiter Summary
This section collects information on the number of current participants (including new and carried-over
participants) and information on those participants who exit the SYS program during the reporting period.
1.

Total Participants – Enter the total number of individuals (including new individuals and participants
carried-over from the prior program year) who received a service under the SYS program during the
reporting period. A participant is any individual who is determined eligible to participate in the program
and receives a service funded by the program. Participant counts do not include individuals who only
receive a determination of eligibility to participate in the program.
1a. Participation in Summer Employment– Enter the total number of individuals that participated in a
summer employment program.

2.

Total Exiters – Enter the total number of participants who exit from the program during the reporting
period.
2a. Summer Employment Exiters– Enter the total number of individuals that participated in a summer
employment program and who exited the program during the reporting period.

3.

Total Current Participants – Subtract line 2 from line 1 above. This is the number of participants remaining
on the program after the end of the reporting period.

Section III. Participant Characteristics Summary
Socio-economic characteristics of participants contained in this section should be based on information collected
from the individual at the time of participation in the SYS program.
4.

Male – Enter the total number of participants whose gender is male.

5.

Female – Enter the total number of new participants whose gender is female.

6.

High School / Pre-High School Student - Enter the total number of participants who have not received a
secondary school diploma or its recognized equivalent and are attending any secondary school (including
elementary, intermediate, junior high school, whether full or part-time, and alternative school), or are
between school terms and intend to return to school.

7.

High School Graduate or Equivalent – Enter the total number of participants who have received a
secondary school diploma or its recognized equivalent.

8.

Post High School Student - Enter the total number of participants who have received a secondary school
diploma or its recognized equivalent and are attending a post-secondary school or program (whether full or
part-time), or are between school terms and intend to return to school.

9.

School Dropout – Enter the total number of participants who are no longer attending any school and have
not received a secondary school diploma or its recognized equivalent.

10. Pregnant and/or Parenting Youth – Enter the total number of Participants (Male/Female) who, at
enrollment, are under 22 years of age and who are pregnant and/or parenting, or who are providing
custodial care for one or more dependents under age 18 as appropriate.
11. Offender - Enter the total number of participants who either (a) are or have been subject to any stage of the
criminal justice process for committing a status offense or delinquent act, or (b) require assistance in
overcoming barriers to employment resulting from a record of arrest or conviction for committing
delinquent acts, such as crimes against persons, crimes against property, status offenses, or other crimes.
12. Foster Child - Enter the total number of participants who are under foster care as determined by the Tribe
or State.
13. Public Assistant Recipient - Enter the total number of participants who were receiving cash assistance or
other support services from one of the following sources: Temporary Assistance for Needy Families, Food
Stamp Assistance, General Assistance (GA) (State/local government), Refugee Cash Assistance (RCA), and
Supplemental Security Income (SSI-SSA Title XVI), Supplemental Security Disability Insurance, Veterans
Benefits, Foster Child Payments, USDA's Commodity Supplemental Food Program (CSFP), Department of
Interior's, Bureau of Indian Affairs, General Assistance or Tribal Work Experience Program (TWEP).
14. Basic Skills Deficiency - Enter the total number of participants who either (a) compute or solve problems,
reads, writes or speaks English (Spanish in Puerto Rico) at or below grade level 8.9; or (b) are unable to
compute or solve problems, read, write, or speak English at a level necessary to function on the job, in the
individual’s family or in society. A determination of basic skills deficiency must be based on a generally
accepted standardized testing instrument or a comparable score on a criterion-referenced test

15. Individual with a Disability – Enter the total number of participants who indicate they have any
“disability,” as defined in Section 3(2)(a) of the Americans with Disabilities Act of 1990 (42 U.S.C. 12102).
Under that definition, a “disability” is a physical or mental impairment that substantially limits one or more
of the person’s major life activities. (For definitions and examples of “physical or mental impairment” and
“major life activities,” see paragraphs (1) and (2) of the definition of the term “disability” in 29 CFR 37.4, the
definition section of the WIA non-discrimination regulations.)
16. In-School Youth – Enter the total number of participants who, at the time of enrollment, were; (a) attending
school (as defined by State law), including secondary and postsecondary school and; (b) Not younger than
age 14 or (unless an individual with a disability who is attending school under State law) older than age 21
at time of enrollment.
17. Out-of-School Youth – Enter the total number of participants who, at the time of enrollment, were; (a) Not
attending any school (as defined under State law); (b) Not younger than age 16 or older than age 24 at time
of enrollment.
18. 14 - 18 - Enter the total number of participants who were between the age of 14 and 18 at the time of
enrollment.
19. 19 - 18 - Enter the total number of participants who were between the age of 19 and 21 at the time of
enrollment.
20. 22 - 24 - Enter the total number of participants who were between the age of 22 and 24 at the time of
enrollment.
21. Eligible Veterans - Enter the total number of participants who, at the time of enrollment, met one of the
following conditions as a veteran:
A. Is a person who served on active duty for a period of more than 180 days and was discharged or released
with other than a dishonorable discharge; or was discharged or released because of a service connected
disability; or as a member of a reserve component under an order to active duty pursuant to section 167
(a), (d), or, (g), 673 (a) of Title 10, U.S.C., served on active duty during a period of war or in a campaign or
expedition for which a campaign badge is authorized and was discharged or released from such duty
with other than a dishonorable discharge; or
B. Is a person who is (a) the spouse of any person who died on active duty or of a service-connected
disability, (b) the spouse of any member of the Armed Forces serving on active duty who at the time of
application for assistance under this part, is listed, pursuant to 38 U.S.C. 101 and the regulations issued
thereunder, by the Secretary concerned, in one or more of the following categories and has been so listed
for more than 90 days: (i) missing in action; (ii) captured in the line of duty by a hostile force; or (iii)
forcibly detained or interned in the line of duty by a foreign government or power; or (c) the spouse of
any person who has a total disability permanent in nature resulting from a service-connected disability or
the spouse of a veteran who died while a disability so evaluated was in existence.

Section IV. Participant Goals and or Attainment Summary
22. Completed Work Readiness - Enter the total number of youth participants enrolled for the reporting period
who completed, during the course of their program participation, a course of instruction relating to job
readiness or world of work skills, including training to develop positive work habits, attitudes and
behavior, such as punctuality, regular attendance, presenting a neat appearance, getting along and working
well with others, exhibiting good conduct, following instructions and completing tasks, accepting
constructive criticism from supervisors and co-workers, showing initiative and reliability, and assuming the

responsibilities involved in maintaining a job. This category also entails developing an awareness of the
labor market and occupational information, and job search techniques, including preparing resumes and
applications and improving interviewing techniques.
23. Completed Internship or Vocational Exploration Program - Enter the total number of youth participants
enrolled for the reporting period who completed, during the course of their program participation, a work
internship or a vocational exploration program designed to provide exposure to alternative career areas.
24. Completed Career Assessment - Enter the total number of youth participants enrolled for the reporting

period who completed, during the course of their program participation, a formal career assessment of
occupational interests, values, skills, or aptitudes, leading to an identification of careers for which the
participant may be suited.

25. Entered Unsubsidized Employment (including military) - Enter the total number of youth participants
enrolled for the reporting period who, upon termination, entered non-WIOA funded employment,
including entry into the Armed Forces or self-employment.
26. Remained in School - Enter the total number of youth participants enrolled for the reporting period

who were at-risk of dropping out of school but, who were retained in school as a result of
continuing active participation in the Supplemental Youth program.

27. Returned to School Full Time - Enter the total number of youth participants enrolled for the reporting
period who, at intake, were not attending school (exclusive of summer), and had not obtained a high school
diploma or equivalent and returned to full-time secondary school (e.g., junior high school, middle school,
and high school) including alternative school as a result of participating in the Supplemental Youth
program.
28. Enrolled in Job Corps – Enter the total number of youth participants enrolled for the reporting period who
enrolled in Job Corps.
29. Improved Basic Skills by at Least Two Grade Levels - Enter the total number of youth participants
enrolled for the reporting period who advanced at least two grade levels in either reading or math skills as a
result of participation in the Supplemental Youth Services Program. [Note: Skill gain must be achieved
through active program participation and must be documented through standardized testing].
30. Attained High School Diploma - Enter the total number of at-risk youth participants enrolled for the
reporting period who attained a State-recognized high school diploma while enrolled in the Supplemental
Youth Program as a result of program participation.
31. Attained GED - Enter the total number of youth participants enrolled for the reporting period who attained
a State-recognized GED while enrolled in the Supplemental Youth Program as a result of program
participation.
32. Completed Occupational Skills Training - Enter the total number of youth participants enrolled for the
reporting period who completed occupational skills training while enrolled in the Supplemental Youth
Program as a result of program participation. [Note: occupational skills training includes (1) vocational
education and (2) on-the-job training].
33. Completed Leadership Skills Training - Enter the total number of youth participants enrolled for the
reporting period who completed during the course of their program participation training that is intended
to impart leadership skills. This category includes providing exposure to post-secondary educational
opportunities; community and service learning projects; peer-centered activities (including peer mentoring
and tutoring); organizational and team work training (including team leadership training); training in
decision-making (including determining priorities); citizenship training (including life skills training such

as parenting and budgeting of resources); positive social behaviors; any organized group counseling
program; or "youth camp".
34. Entered Other (Non-Supplemental Youth) Training Program - Enter the total number of youth
participants enrolled for the reporting period who entered other training, including occupational skills
training or postsecondary education, using funds other than those from the INA Supplemental Youth
Services Program which builds upon and does not duplicate training received under Section 166. [This
category excludes those enrolled in Job Corps.]
35. Successful Completion of Summer Employment - Enter the number of youth participants from line 1.a.
above that successfully completed their Summer Employment.

Section V. Performance Outcomes
This section collects information on important outcomes achieved by participants of the SYS Program. Grantees
are required to submit results for both the current semi-annual period (Column B) and cumulative totals for the
program-to-date (Column C). Grantees are required to report both the numerator and denominator values for
each performance measure contained in this section. This detail is needed so that the information can be
aggregated across grantees to provide national estimates. The EBSS on-line reporting system will automatically
calculate the percent or rate for each measure.
36. Attainment of Two or More Goals
Numerator:
Enter the number of individuals that attained at two or more of the goals/attainment in
Section IV above.
Denominator:
Enter the total number of participants in line 1 above.
37. Educational Attainment for Dropouts
Numerator:
Enter the number of individuals that attained a high school diploma, GED, or increased their
literacy and numeracy by two grade levels divided (i.e. the sum of lines 29, 30 & 31 above).
Denominator:
Enter the total number of dropouts from line 9 above.
Remarks

Grantees may include additional information not captured as part of the report format in the
remarks section