Employer Information

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Todd Townsend
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1 1. Name of participant: 2. PID: Participant ID Number assigned by SPARQ Employer Information 3. Name of employer Name of organization or employer 4. Employer mailing address a. Number and Street, Suite Number; and/or PO Box b. City c. State d. Zip Code 5. Federal Employer Identification Number (FEIN) 6. Employer type (select one) Not-for-profit For-profit Government Self-employment Self-employment may be verified by any proof that the individual has started a business, such as tax registration, business cards or invoices, or a state license. The individual does not have to prove income from the business, but the receipt of income would suffice to establish self-employment. 7. Is employer a host agency? Yes No 8. Did employer provide an OJE training site for this participant? Yes No 8. DV TIP: Official subgrantee record that establishes the approval of an OJE for the Participant and the existence of a signed contract. Authorized for Local Reproduction ETA-9122 (Revised February 2015; replaces prior versions) This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No Persons are not required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this collection of information required to obtain or retain benefits (PL Sec ) is estimated to average six (6) 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 or any other aspect of this collection, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Adult Services, Room S-4203, 200 Constitution Avenue, NW, Washington, DC (PRA Project ). Participant Name Page 1

2 9. Employment site name and location 9a. *Employer received customer satisfaction survey in PY 9b. Employer continued availability Available Not available Employer Contact/Supervisor Information 10. Name of contact person: 11. Contact person s mailing address if different from number 4 a. Organization name or address field 1 b. Number and Street, Suite Number; and/or PO Box or address field 2 c. City d. State e. ZIP Code 12. Contact person s title: 12a. Contact person s salutation: Mr. Ms. Dr. 13. Contact person s phone number 13a. Contact person s fax number 13a1. Contact person s cell phone number 13b. Contact person s address * No data entry in SPARQ. Field is system-generated. Participant Name Page 2

3 Complete fields 13c-13i if supervisor is different from contact person (number 10). If supervisor is the same as contact person, skip to field c. Name of supervisor: 13d. Supervisor s mailing address if different from number 4 a. Organization or address field 1 b. Number and Street, Suite Number; or PO Box or address field 2 c. City d. State e. ZIP Code 13e. Supervisor s title: 13f. Supervisor s salutation Mr. Ms. Dr. 13g. Supervisor s phone number: 13h. Supervisor s fax number: 13h1. Supervisor s cell phone number: 13i. Supervisor s address: Placement Information 14. Start date: (MM/DD/YYYY) 15. End date: (MM/ DD/YYYY) 16. Starting wage per hour $ (not required for self-employed) Participant Name Page 3

4 17. Benefits (check all that apply) a. Health insurance d. Vacation g. Other (specify) b. Sick leave e. Transportation h. None c. Pension/profit sharing f. Room and board 18. At time of placement, is employment expected to be full- or part-time? Full-time Part-time Full-time work means work of at least 40 hours per week, or such lesser amount as determined by the employer, to constitute full-time work. If part-time, number of hours per week expected: 19. Unsubsidized Job title: 19a. Participant s job code: 1. Art, Design, Entertainment, Sports, and Media 8. Food Preparation and Service 15. Production, Assembly, Light Industrial 2. Business and Financial Operations 9. Healthcare 16. Protective Service 3. Community and Social Services 10. Legal 17. Retail, Sales, and Related 4. Computer and Mathematical 11. Maintenance and Custodial 18. Self-Employment 5. Construction, Installation, and Repair 12. Management 19. Transportation and Material Moving 6. Education, Training, and Library 13. Office and Administrative Support 7. Farming, Fishing, and Forestry 14. Personal Care and Service 19b. High-growth industry placement (select one) 1. Automotive 6. Financial Services 11. Retail 2. Advanced Manufacturing 7. Geospatial 12. Transportation 3. Biotechnology 8. Health Care 13. None 4. Construction 9. Hospitality 5. Energy 10. Information Technology 20. Is the job a training-related placement? This means is the participant s unsubsidized job related to the host agency training or other training they received from SCSEP? Yes No 21. Was placement the result of a substantial service provided to the employer by the subgrantee? Yes We referred the applicant to the employer and the employer was aware of the referral. No The participant found the unsubsidized job solely on his or her own or is self-employed. Participant Name Page 4

5 22. Unsubsidized employment comments: Name of source of the information: His/her phone number: His/her organization and title or relationship to participant: Name or initials of person making note: Date the information was obtained: Detailed Case Notes reflecting the reason for the break, the start date and if applicable (end date) and that the break is authorized through your approved break policy: Employer Customer Service (CS) Survey Information See SCSEP Policy and Procedure #900-D for Instructions regarding the Employer Satisfaction Survey. 23. CS survey number 1 Date (MM/DD/YYYY) 24. CS survey number 2 Date (MM/DD/YYYY) 25. CS survey number 3 Date (MM/DD/YYYY) Participant Name Page 5

6 Follow-up Information 26. *90-day date (MM/DD/YYYY) 27. Has the participant returned to program within the first 90 days after exit? Yes No 27a. Has the participant re-enrolled in SCSEP within the first 90 days after exit? Yes No 28. Follow-up 1 a. * Scheduled date: (MM/DD/YYYY) b. Completed date: (MM/DD/YYYY) c. Any wages for first quarter after exit quarter? Please also indicate method of verification i. No wages vi. Yes, supplemental through case management, participant survey, 28c. vi DV TIP: and/or verification with the employer Self-attest form, secure pay stubs, written vii. Unable to obtain information statement of earnings from employer, or viii. Excluded detailed case notes to validate. c1. If excluded, reason i. Deceased DV Tip: 3 rd party attest, or death record or certification; or death notice published through the Internet, in newspaper, and local funeral homes, or detailed case notes. ii. Health/medical iii. Family care iv. Institutionalized Veteran s medical records, vocational rehabilitation letter, workers compensation record; or detailed case notes. In addition to the standard requirements for all case notes, to establish exclusion for institutionalized, case notes must also detail that the participant is receiving 24-hour care in a facility like a prison or hospital and is expected to remain there for at least 90 days. A disabled person residing in a facility is not considered institutionalized. * No data entry in SPARQ. Field is system-generated. Participant Name Page 6

7 29. Follow-up 2 a. *Scheduled date: (MM/DD/YYYY) b. Completed date: (MM/DD/YYYY) c. Any wages for second quarter after exit quarter? Please also indicate method of verification i. No wages vi. vii. viii. Yes, supplemental through case management, participant survey, and/or verification with the employer Unable to obtain information Excluded 29c. vi DV TIP: Self-attest form or secure pay stubs, written statement of earnings from employer, or detailed case notes to validate. c1. If excluded, reason i. Deceased DV Tip: 3 rd party attest, or death record or certification; or death notice published through the Internet, in newspaper, and local funeral homes, or detailed case notes. ii. Health/medical iii. Family care iv. Institutionalized Veteran s medical records, vocational rehabilitation letter, workers compensation record; or detailed case notes. In addition to the standard requirements for all case notes, to establish exclusion for institutionalized, case notes must also detail that the participant is receiving 24-hour care in a facility like a prison or hospital and is expected to remain there for at least 90 days. A disabled person residing in a facility is not considered institutionalized. d. If yes, earnings for second quarter after exit quarter $ *No data entry in SPARQ. Field is system-generated. 29d. DV TIP: Earnings information must come from pay stubs, or a written statement from the employer, or case notes based on information from the employer. Participant Name Page 7

8 e. Any wages for third quarter after exit quarter? Please indicate method of verification i. No wages vi. Yes, supplemental through case management, participant survey, and/or verification with the employer vii. Unable to obtain information viii. Excluded 29e. vi DV TIP: Self-attest or secure pay stubs, written statement of earnings from employer, or detailed case notes to validate. e1. If excluded, reason i. Deceased DV Tip: Death record or certification; or death notice published through the Internet, in newspaper, and local funeral homes or 3 rd party attestation, or detailed case notes. ii. Health/medical DV Tip: Medical records or other official records including but not limited to actual medical records, physician s statement or other certification from a medical professional, letter from official at a medical facility or institution, psychologist s diagnosis, rehabilitation evaluation, disability records, Veteran s medical records, vocational rehabilitation letter, workers compensation record; or self-attest or third party attestation. iii. Family care DV Tip: Medical records or other official records including but not limited to actual medical records, physician s statement or other certification from a medical professional, letter from official at a medical facility or institution, psychologist s diagnosis, rehabilitation evaluation, disability records, Veteran s medical records, vocational rehabilitation letter, workers compensation record; or self-attest or third party attestation. iv. Institutionalized DV Tip: Medical records or other official records including but not limited to actual medical records, physician s statement or other certification from a medical professional, letter from official at a medical facility or institution, psychologist s diagnosis, rehabilitation evaluation, disability records, Veteran s medical records, vocational rehabilitation letter, workers compensation record; or self-attest or third party attestation; or detailed case notes. In addition to the standard requirements for all case notes, to establish exclusion for institutionalized, case notes must also detail that the participant is receiving 24-hour care in a facility like a prison or hospital and is expected to remain there for at least 90 days. A disabled person residing in a facility is not considered institutionalized. f. If yes, earnings for third quarter after exit quarter $ 29f. DV TIP: Earnings information must come from pay stubs, or a written statement from the employer, or case notes based on information from the employer. Participant Name Page 8

9 30. Follow-up 3 a. *Scheduled date (MM/DD/YYYY) b. Completed date (MM/DD/YYYY) c. Any wages for fourth quarter after exit quarter? Please also indicate method of verification i. No wages vi. Yes, supplemental through case management, participant survey, and/or verification with the employer vii. Unable to obtain information viii. Excluded 30c. vi DV TIP: Self-attest or secure pay stubs, written statement of earnings from employer, or detailed case notes to validate. c1. If excluded, reason i. Deceased DV Tip: 3 rd party attest, or death record or certification; or death notice published through the Internet, in newspaper, and local funeral homes, or detailed case notes. ii. Health/medical iii. Family care iv. Institutionalized Veteran s medical records, vocational rehabilitation letter, workers compensation record; or detailed case notes. In addition to the standard requirements for all case notes, to establish exclusion for institutionalized, case notes must also detail that the participant is receiving 24-hour care in a facility like a prison or hospital and is expected to remain there for at least 90 days. A disabled person residing in a facility is not considered institutionalized. *No data entry in SPARQ. Field is system-generated. Participant Name Page 9

10 31. Customer satisfaction and follow-up comments. Name of source of the information: His/her phone number: His/her organization and title or relationship to participant: Name or initials of person making note: Date the information was obtained: Detailed Case Notes: Participant Name Page 10

SCSEP Unsubsidized Employment Form OMB Control Number: Expiration Date: 8/31/2018

SCSEP Unsubsidized Employment Form OMB Control Number: Expiration Date: 8/31/2018 OMB Control Number: 1205-0040 Expiration Date: 8/31/2018 1. Name of participant 2. PID Employer Information 3. Name of employer 4. Employer mailing address a. Number and street, suite number; and/or PO