Form ETA 9190A, 9190B a ETA 9190A, 9190B a Grant Data Collection Form

U.S. Department of Labor Employment and Training Administration Office of Job Corps

ETA PLAN: 9190 OMB Control No. 1205-0219 Expiration Date: 05/31/2025

Grants Data Collections Forms

Purpose of this form: This form is used to report data within the GDC system for calculating the performance outcomes required under their FOA and WIOA.

Job Corps Grantee Data Collection: Applicant Data (9190C)

Program Name			Provider
Legal Name			Date Application Completed
Applicant ID			Most Recent Date Application Modified
Social Security Number

Personal Information
Date of Birth
Sex	☐ Male ☐ Female
Ethnicity	☐ Hispanic/Latino ☐ Not Hispanic/Latino ☐ Did not self-identify
Race	(select all that apply) ☐ American Indian / Alaska Native ☐ Asian ☐ White ☐ Native Hawaiian / Other Pacific Islander ☐ Black /African American ☐ Did not self-identify
Address:
State
County
Zip Code

Academic and Employment Background at Time of Application
Highest School Grade Completed
Highest Education Level Completed		☐ None ☐ HSD ☐ HSE ☐ Certificate of Attendance/Completion of IEP ☐ Some Post-secondary ☐ AA/AS ☐ Post-secondary Technical/Vocational Certificate ☐ Other:
Filed Unemployment Compensation Claim and Is Eligible for Benefits		☐ Yes ☐ No
Referral by: (select one)		☐ RESEA ☐ WPRS ☐ Exhausted Benefits ☐ Exempt from Work Search Requirements ☐ Other:
Received Public Assistance in the Last Six Months (Select all that apply)
☐ Temporary Assistance for Needy Families (TANF) ☐ SSI ☐ SSDI ☐ TICKET TO WORK HOLDER ☐ General Assistance (GA) (State/local government) or Refugee Cash Assistance (RCA) ☐ None
Additional Youth Characteristics at Program Application: (Select All That Apply)
☐ Foster Care ☐ Homeless ☐ Runaway Youth ☐ Low-income Status ☐ English Language Learner ☐ Basic Skills Deficient/Low Levels of Literacy
Cultural Barriers:	☐ Yes	☐ No	☐ Did Not Self-Disclose
Single Parent:	☐Yes	☐ No	☐ Did Not Self-Disclose
Military Experience
Served or Serving on Active Duty in U.S. Armed Forces	☐ Yes	☐ No	☐ Did Not Self-Disclose
Date of Separation
Length Of Service		☐ Served 180 days or less on active duty ☐ Served more than 180 days on active duty
Service Type		☐ Served on active duty during war/campaign/expedition, and ☐ Served as part of a reserve component
Discharge Type		☐ Honorable ☐ Other Than Honorable ☐ General ☐ Bad Conduct ☐ Dishonorable ☐ Other Other: (select all that apply) ☐ Discharged from active duty for a service-connected disability ☐ Entitled to compensation regardless of rating (including 0%), or entitled but receives military retirement pay, under laws administered by DVA ☐ Entitled to compensation, or entitled but receives military retirement pay, under laws administered by DVA for a disability rated at (i) 30% or more OR (ii) 10% or 20% if determined to have a serious employment handicap ☐ Homeless veteran
Currently Serving in U.S. Armed Forces And is Within 12 Months of Separation or 24 Months 0f Retirement		☐ Yes ☐ No
Applicant’s Spouse Served on Active Duty in U.S. Armed Forces		☐ Yes ☐ No ☐ Spouse died on active duty or of service-related disability ☐ Spouse missing in action for 90 or more days at time of application OR Spouse captured in line of duty by hostile force, or forcibly detained/interned in line of duty by foreign government or power for 90 or more days at time of application ☐ Spouse has a total, permanent disability from a service-connected disability or died with such a disability
Disability Status
Applicant Disclosed a Disability		☐ Yes ☐ No ☐ Did Not Self-Disclose
Disability Type (select all that apply)		☐ Mental or Psychiatric Disability ☐ Vision-related disability ☐ Hearing-related disability ☐ Learning Disability ☐ Cognitive/Intellectual disability ☐ Applicant did not disclose type of disability
Applicant Received Services Funded By (select all that apply)		☐ SDDA ☐ LSMHA ☐ State Medicaid HCBS Waiver ☐ No Services Funded By These Sources
Type of Work Setting (select all that apply)		☐ Working in competitive, integrated employment (CIE)  Working in group supported employment ☐ Working in a sheltered workshop ☐ Previously employed in supported employment ☐ Not Currently Employed
Applicant Received Customized Employment Services (CES):		☐ Yes ☐ No Type of CES: (select one) ☐ Discovery assessment services ☐ Developed a customized employment search plan ☐ Employer negotiation services ☐ Secured employment as a result of receiving customized employment services and received extended support services

Paperwork Reduction Act Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 113-128). Public reporting burden is estimated to average 10 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 U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0219). Please do not submit completed forms to this address.

Job Corps Grantee Data Collection: Enrollee Data (9190B)

Program Name			Provider
Applicant Name			Date of Enrollment
Applicant ID			Date of Exit
Social Security Number

Education Services Received
Enrolled In (select all that apply)				☐ NONE ☐ SECONDARY PROGRAM ☐ POST-SECONDARY PROGRAM
Program #1:	Start Date: Date Credential Attained:	Credential Type:		☐HSD ☐ HSE ☐ AA/AS ☐ Other:
Program #2:	Start Date: Date Credential Attained:	Credential Type:		☐HSD ☐ HSE ☐ AA/AS ☐ Other:
Program #3:	Start Date: Date Credential Attained:	Credential Type:		☐HSD ☐ HSE ☐ AA/AS ☐ Other:
Academic Milestones Achieved
Date of Most Recent Transcript/Report Card From			Date
☐ Post-secondary program with 12+ credit hours in a semester (FT) or over 2 semesters (PT) meeting state unit’s academic standards
☐ Secondary program meeting state unit’s academic standards
SCHOLARS GRANTS ONLY: Total Academic Hours Earned since Program Start:

Training Services Received
Entered Training Program:	☐ YES ☐NO
☐ Training # 1:	Type	Start Date:	Completion Date:
☐ Training # 2:	Type	Start Date:	Completion Date:
☐ Training # 3:	Type	Start Date:	Completion Date:
Training-Related Credentials Attained
Record Industry-Recognized Credential or Certification, Certificate of Completion of a Registered Apprenticeship, or a State or Federal-recognized license attained during program enrollment
☐ Credential #1:	Date Credential Attained:		Type: ☐ Licensure ☐ Certificate ☐ Certification ☐ Other
☐ Credential #2:	Date Credential Attained:		Type: ☐ Licensure ☐ Certificate ☐ Certification ☐ Other
☐ Credential #3:	Date Credential Attained:		Type: ☐ Licensure ☐ Certificate ☐ Certification ☐ Other

Training Milestones Achieved
☐ Completed an exam that is required for a particular occupation		Most Recent Date Achieved:
☐ Progress in attaining technical or occupational skills as evidenced by trade-related benchmarks such as knowledge- based exams.		Most Recent Date Achieved:
☐ A satisfactory or better progress report towards established milestones from an employer/training provider who is providing training (e.g., completion of on-the-job training (OJT), completion of one year of a registered apprenticeship program, etc.).		Most Recent Date Achieved:
EFL Gains
Reading
Category Of Assessment:		☐ABE ☐ ESL ☐ NONE
Test Type:		☐ TABE 11/12 ☐ CASAS ☐ OTHER:
Date of Initial Test:	Initial Test Score		Initial Test EFL
Date of Post-Test:	Post-Test Score		Post-Test EFL
Math
Category Of Assessment:		☐ABE ☐ ESL ☐ NONE
Test Type:		☐ TABE 11/12 ☐ CASAS ☐ OTHER:
Date of Initial Test:	Initial Test Score		Initial Test EFL
Date of Post-Test:	Post-Test Score		Post-Test EFL
Other
Category Of Assessment:		☐ABE ☐ ESL ☐ NONE
Test Type:		☐ TABE 11/12 ☐ CASAS ☐ OTHER:
Date of Initial Test:	Initial Test Score		Initial Test EFL
Date of Post-Test:	Post-Test Score		Post-Test EFL
Exit Status
NON-SCHOLARS GRANTS ONLY: ☐ Graduate ☐ Former Enrollee ☐ Other:
SCHOLARS GRANTS ONLY: ☐ Program Completer ☐ Program Non-Completer
Exit Reason
☐ Institutionalized ☐ Health/Medical ☐ Deceased ☐ Reserve Forces called to Active Duty ☐ Foster Care ☐ Ineligible ☐ Criminal Offender ☐ None of the above
Paperwork Reduction Act Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 113-128). Public reporting burden is estimated to average 10 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 U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0219). Please do not submit completed forms to this address.

Job Corps Grantee Data Collection: Post Separation Data (9190A)

Program Name				Provider
Applicant Name
Applicant ID
Social Security Number

Post-Separation Placement

Qualifying Student Placement (select one)

☐ One Full Time Job	☐ Registered Apprentice Full Time Job	☐ Other Training Program
☐ Two Full Time Jobs	☐ Full Time Job/College Combo	☐ OJT/Paid Employment
☐ One Part Time Job	☐ Part Time Job/College Combo	☐ High School Diploma (HSD) Program
☐ Two Part Time Jobs	☐ College	☐ High School Equivalency (HSE) Program
☐ Armed Forces	☐ Post-Secondary School/Training	☐ Not Placed

Job Training Match: ☐ Yes ☐ No

Date First Reported to Placement:

Hourly Wage at Placement: $ .

Date Met Placement Hours/Wage/Credit Requirements:

Hourly Wage at Six Months After Placement: $ .

SCHOLARS GRANTS ONLY:

Hourly Wage at 12 Months After Placement:$ .

First Quarter After Exit

Type of Employment

☐ Military

☐ Registered Apprenticeship

☐ Other unsubsidized employment

☐ Not employed

Date First Entered Employment

Date Exited Employment (if applicable):

Data Source

☐ UI Wage Data

☐ Federal Employment Records (OPM, USPS)

☐ Military Employment Records (DOD)

☐ Non-UI verification

Quarterly Earnings

$

Post-secondary Enrollment and Degree Attainment

☐ Enrolled in Post-Secondary Education/Training

Date Enrolled:

☐ Attained HSD

Date Attained:

☐ Attained HSE

Date Attained:

☐ Attained AA/AS

Date Attained:

Second Quarter After Exit

Type of Employment

☐ Military

☐ Registered Apprenticeship

☐ Other unsubsidized employment

☐ Not employed

Date First Entered Employment

Date Exited Employment (if applicable)

Data Source

☐ UI Wage Data

☐ Federal Employment Records (OPM, USPS)

☐ Military Employment Records (DOD)

☐ Non-UI verification

Quarterly Earnings

$

Type of Education/Training program

☐ None

☐ Occupational Skills Training

☐ Postsecondary Education

☐ Secondary Education

Start Date of Education/Training program

Post-secondary Enrollment and Degree Attainment

☐ Enrolled in Post-Secondary Education/Training

Date Enrolled:

☐ Attained HSD

Date Attained:

☐ Attained HSE

Date Attained:

☐ Attained AA/AS

Date Attained:

Third Quarter After Exit

Type of Employment

☐ Military

☐ Registered Apprenticeship

☐ Other unsubsidized employment

☐ Not employed

Date First Entered Employment

Date Exited Employment (if applicable):

Data Source

☐UI Wage Data

☐Federal Employment Records (OPM, USPS)

☐Military Employment Records (DOD)

☐Non-UI verification

Quarterly Earnings

$

Post-secondary Enrollment and Degree Attainment

☐ Enrolled in Post-Secondary Education/Training

Date Enrolled:

☐ Attained HSD

Date Attained:

☐ Attained HSE

Date Attained:

☐ Attained AA/AS

Date Attained:

Fourth Quarter After Exit

Type of Employment

☐ Military

☐ Registered Apprenticeship

☐ Other unsubsidized employment

☐ Not employed

Date First Entered Employment

Date Exited Employment (if applicable):

Data Source

☐ UI Wage Data

☐ Federal Employment Records (OPM, USPS)

☐ Military Employment Records (DOD)

☐ Non-UI verification

Quarterly Earnings

$

Type of Education/Training program

☐ None

☐ Occupational Skills Training

☐ Postsecondary Education

☐ Secondary Education

Start Date of Education/Training program

Employed by Same Employer in Q2 and Q4

☐ Yes

☐ No

Paperwork Reduction Act Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 113-128). Public reporting burden is estimated to average 10 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 U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0219). Please do not submit completed forms to this address.

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