TEGL_17-20_Attachment-1_acc.pdf

ETA Advisory File Text

Attachment I SCSEP Participant Data Collection Sample Template I-1 Participant Information 1. Last name 2. First name 3. Middle initial 4. Social Security 4a. Participant ID 5. Home phone 5a. Cell phone 6. Mailing address a. Number and Street Apt. Number or PO Box b. City c. State d. ZIP Code e. County 6a. Participant s e-mail address 6b. Emergency contact Name Phone Relationship 7. State of residence if different from mailing address 8. Homeless Yes No 8a. Urban rural Urban Rural 9. Application date for enrollment or re-enrollment MM DD YYYY Eligibility Information 10. Date of birth MM DD YYYY 11. Number in family 12. Receiving public assistance Check as many as apply a. No b. Supplemental Security Income SSI c. TANF d. State or local welfare General Assistance e. Suppl. Nutrition Assistance SNAP f. Subsidized housing g. Social Security Disability SSDI h. Other specify 13. Employed prior to participation i. Employed ii. Employed but with notice of termination iii. Not employed 14. Total includable family income 12-month or 6-month annualized 15. Family income at or below 100 of poverty level Yes No Attachment I SCSEP Participant Data Collection Sample Template I-2 16. Formerly a participant in any SCSEP project Yes No 17. Tr ansfe rred from another project Yes No If yes specify prior grantee code Date of transfer 17a. Change of sub-grantee Yes No If yes specify prior sub-grantee code Date of change Other Personal Characteristics and Information 18. Gender Male Female Did not voluntarily report 19. Ethnicity Hispanic Latino or Spanish origin Yes No Did not voluntarily report 20. Race Check as many as apply a. American Indian or Alaskan Native b. Asian c. Black African American d. Native Hawaiian Pacific Islander e. White f. Did not voluntarily report 21. Education last grade completed Select one code from following list 0 0 n o grade school 1-11 years of school A11 completed 12 years of school but no HS diploma 12 HS diploma 88 GED or certificate of equivalency for HS 13-15 years of school completed 1-3 years of college 16 B A BS or equivalent 17 education beyond a bachelor s degree 18 master s degree 19 doctoral degree 21 vocational technical degree 22 associate s degree 22. Lim ited English Proficiency LEP Yes No 23. If LEP please specify primary language Select one code from following list 1 0. Amharic 11. Arabic 12. Armenian 13. Bosnian 14. Cantonese Yue 15. French 16. French Creole 17. German 18. Greek 19. Gujarathi 20. Hebrew 21. Hindi 22. Miao Hmong 23. Italian 24. Hungarian 25. Ilocano 26. Japanese 27. Korean 28. Laotian 29. Mandarin 30. Mon-Khmer Cambodian 31. Navajo 32. Persian including Dari 33. Polish 34. Portuguese 35. Punjabi 36. Russian 37. Samoan 38. Serbo-Croatian 39. Somali 40. Spanish 41. Tagalog 42. Thai 43. Urdu 44. Vietnamese 45. Yiddish 46. Other 24. Low lit eracy skills Yes No Attachment I SCSEP Participant Data Collection Sample Template I-3 25. Veteran or eligible spouse of veteran a. Veteran b. Eligible spouse of veteran c. Non -covered person If veteran post -9 11 era veteran Yes No 26. Disability Yes self -report No Yes documentation Did not voluntarily report 27. At risk of homelessness Yes No 28. Displaced homemaker Yes No 29. Failed to find employment af ter using WIA Title I Yes No 30. Low employment prospects Yes No 30a. Incarcerated or under supervision following release from prison or jail with in the last 5 years Ye s No 31. Personal characteristics comments Attachment I SCSEP Participant Data Collection Sample Template I-4 Certification I hereby certify that the above information is true and accurate to the best of my knowledge and belief. I understand that if I intentionally provide inaccurate information I may be terminated from the SCSEP program and may be subject to legal penalties. 32. Signature of applicant 33. Date of signing MM DD YYYY Attachment I SCSEP Participant Data Collection Sample Template I-5 Eligibility Determination 34. Eligible Ineligible 35. If ineligible reason Check as many as apply a. Age b. Income c. Residence outside of state d. Failed to complete application or provide required documentation e. Other specify 36. If ineligible action taken Check as many as apply a. Referred to One-Stop b. Referred to social services c. Referred to another project d. Placed in unsubsidized employment pursuant to MOU e. Other specify Enrollment Information 37. Placed on waiting list Yes No 38. Community service assignment Yes No 39. Grantee name 39a. County of authorized position 40. Co-enrollments Check as many as apply a. WIOA b. Employment Service c. Adult Education d. College Community College e. Other specify f. None 40a. Date of orientation MM DD YYYY 40b. Date of last physical or waiver MM DD YYYY 40c. Date of last IEP MM DD YYYY Attachment I SCSEP Participant Data Collection Sample Template 40d. Job interest codes 1 2 3 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 13. Office and Administrative Support 14. Personal Care and Service 15. Production Assembly Light Industrial 16. Protective Service 17. Retail Sales and Related 18. Self-Employment 19. Transportation and Material Moving 41. Enrollment comments 42. Signature of director or authorized representative 43. Date of eligibility determination MM DD YYYY I-6 Attachment I SCSEP Participant Data Collection Sample Template I-7 Recertification 44. Number in family 45. Total includable family income 12-month or 6-month annualized Certification I hereby certify that the above information is true and accurate to the best of my knowledge and belief. I understand that if I intentionally provide inaccurate information I may be terminated from the SCSEP program and may be subject to legal penalties. 46. Signature of participant on recertification 47. Eligible Ineligible 48. If ineligible reason Check as many as apply a. Income b. Failed to complete application or provide required documentation c. Other specify 49. Signature of director or authorized representative on recertification 50. Date of recertification determination MM DD YYYY Attachment I SCSEP Participant Data Collection Sample Template I-8 Waiver of Durational Limit 51. Severe disability Yes No 51a. Date of last update MM DD YYYY 52. Frail Yes No 52a. Date of last update MM DD YYYY 53. Old enough for but not receiving SS Title II Yes No 53a. Date of last update MM DD YYYY 54. Severely limited employment prospects in area of persistent unemployment Yes No 54a. Date of last update MM DD YYYY 55. Limited English Proficiency LEP Yes No 55a. Date of last update MM DD YYYY 56. Low literacy skills Yes No 56a. Date of last update MM DD YYYY 57. 75 or over Yes No 58. Incarcerated or under supervision following release from prison or jail within the last 5 years Yes No 58a. Date of last update MM DD YYYY 5 9. Recertification waiver commen ts