Form ETA 9120 ETA 9120 SPARQ Participant Form

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Overview

ETA 9120
System Element
Participant Job Codes

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Sheet 1: ETA 9120

OMB Control Number 1205-0040 ETA 9120 - Participant Expiration Date: 08-31-2018
DATA ELEMENT NAME	DATA TYPE/ FIELD LENGTH	DATA ELEMENT DEFINITIONS/INSTRUCTIONS	CODE VALUE
Primary Phone Extension	IN 10	Record Applicant primary phone extension
Alternate Phone Extension	IN 10	Record Applicant alternate phone extension
Check if different	Checkbox	Check if mailing address is different
Zip+4	IN 4	Record applicant Zip+4	XXXX
Case Manager	AN 26	Record participant case manager
Other Barrier	AN 225	Record applicant's other barrier
Eligibility Verified On	DT 8	Record the date in which eligibility was verified on	YYYYMMDD
Extension Option	IN	Record extension option	40 No extensions 41 Allow all the waiver factors 42 Allow only a subset of waiver factors
Extension Option Effective Date	DT 8	Record extension option effective date	YYYYMMDD
Qualifying Waiver Factors	IN	Select all qualifying waiver factors	Severe Disability Frail Old Enough but Not Receiving SS Title I Severely Limited Employment Prospects Limited English Proficiency Low Literary Status 75 or Older
Number of Extensions a Participant May Receive	IN 1	Record 1 if the number of extensions a participant may receive is one time only Record 2 if the number of extensions a participant may receive is unlimited with annual approval Record 1 if the number of extensions a participant may receive is limited	1= One time only 2= Unlimited with Annual Approval 3= Limited
Number of Extensions	IN	Record number of extensions if limited extension is being granted
Extension Comments	AN 225	Record extensions comments
Address of Residence if Different from Mailing Address	IN 1	Record 1 if address of residence is different from mailing address Record 0 if address of residence is not different from mailing address	1=Yes 0=No
Mailing Address	AN 225	If address of residence is different from mailing address, record mailing address
Address Line 1	AN 225	If address of residence is different from mailing address, record address line 1
Address Line 2	AN 225	If address of residence is different from mailing address, record address line 2
City	AN 225	If address of residence is different from mailing address, record city
State	AN 2	If secondary contact information is available, record state
Zip	IN 5	If address of residence is different from mailing address, record zip	00000
County	AN 225	If address of residence is different from mailing address, record county	00000
Address Line 2	AN 225	If secondary contact information is available, record address line 2
City	AN 225	If secondary contact information is available, record city
State	AN 2	If secondary contact information is available, record state
Is Family Income At or Below 125% poverty level?	IN 1	Record 1 if participant family income at or below 125% poverty level Record 2 if participant family income is not at or below 125% poverty level Note: System-generated	1 = Yes 0 = No
Alternate Phone	IN 10	If secondary contact information is available, record alternate phone
Ext.	IN 10	If secondary contact information is available, record alternate phone ext.
E-mail	AN 225	If secondary contact information is available, record e-mail
Address Line 1	AN 225	If secondary contact information is available, record address line 1
Zip	IN 5	If secondary contact information is available, record zip
Primary Phone	IN 10	If secondary contact information is available, record primary phone
Ext.	IN 10	If secondary contact information is available, record primary phone ext.
Last Name	AN 225	Record participant last name
First Name	AN 225	Record participant first name
Middle Initial	AN 1	Record participant middle initial	X
Primary Phone	IN 10	Record Applicant primary phone
Alternate Phone	IN 10	Record Applicant alternate phone
Address of Residence	AN 225	Record applicant address of residience. If the applicant does not have a residence, try to obtain an address at which the applicant can receive mail. The mailing address fields will be used to mail letters and the customer satisfaction survey.
Address Line 1	AN 225	Record applicant address of residence line 1
Address Line 2	AN 225	Record applicantaddress of residence line 2
City	AN 225	Record applicantaddress of residence city
State of residence if different mailing address	AN 2	Record the state of residence if different from mailing address. Residence is defined as an individual’s primary dwelling place or address as demonstrated by appropriate documentation. A homeless individual is considered a resident of the state in which he or she is applying. Grantees may accept residents of other states if there is an approved multi-state agreement.	XX
Zip	IN 5	Record the 5-digit zip code of the state of residence if different from mailing address.	00000
County	AN 26	Record the county of the state of residence if different from mailing address.	00000
Email	AN 225	Record applicant email address
Secondary Contact Name	IN 1	Record 1 if secondary contact information is available Record 0 if Secondary contact information is not available	1=Yes 0=No
Contact Name	AN 225	If secondary contact information is available, record applicant contact name
Primary Phone	IN 10	If secondary contact information is available, record applicant contact primary phone
Relationship to Participant	AN 225	If secondary contact information is available, record relationship to applicant
Formerly a participant in any SCSEP project	IN 1	Record 1 if the applicant reports that he or she was ever enrolled in any SCSEP project. Record 0 if the applicant did not report that he or she was ever enrolled in any SCSEP project. Note: System-generated	1 = Yes 0 = No
Race	IN 1	Record 1 if participant identified race Record 2 if participant did not identify race	1 = Yes 2 = No
Primary Language	IN 2	Specify primary language	10= 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
Please, Specify Other	AN 225	Other Primary Language Text
Individual with a Disability?	IN 1	Record 1 if the participant indicates that he/she has any "disability”, SCSEP defines “disability” as: a condition attributable to mental or physical impairment, or a combination of mental and physical impairments, that results in substantial functional limitations in one or more of the following areas of major life activity: (A) self-care; (B) receptive and expressive language; (C) learning; (D) mobility; (E) self-direction; (F) capacity for independent living; (G) economic self-sufficiency; (H) cognitive functioning; and (I) emotional adjustment. Record 0 if the participant indicates that he/she does not have a disability that meets the definition. Record 9 if the participant did not self-identify.	1 = Yes 0 = No 9 = Participant did not self-identify
Eligibility Characteristics Comments	AN 2000	Record Eligibility Characteristics Comments
Signature of applicant (Did Applicant Sign the Applicant Certificate)	IN 1	Record 1 if Applicant signed the Applicant Form Record 0 if Applicant did not sign the Applicant Form	1=Yes 0=No
Date of signing (The applicant signed the Applicant Certification on	DT 8	Record the Date that the applicant signed the Applicant Certification	YYYYMMDD
Additional Reasons for Ineligibility	IN 1	Record 4 if applicant is not eligible due to Age Record 5 if applicant is not eligible due to Residence Outside of State Record 6 if applicant is not eligible due to being employed at the time intake	4=Age 5=Residence Outside of State 6=Employed
Other Reason	AN 2000	Specify other reason for ineligibility
Action Taken if Ineligible	Checkbox	Select all that applies for action taken for ineligibility	Referred to One-Stop Referred to Social Services Referred to another project Placed in unsubsidized employment pursuant to MOU Other
Other Action	AN 225	Specify other action taken from ineligibility
Was the Participant Given a Community service assignment?	IN 1	Record 1 if applicant was assigned to a community service assignment. Record 0 if applicant was not assigned to a community service assignment.	1 = Yes 0 = No
College/Community College	IN 1	Record 1 if the participant recieve services from a College/Community College Record 0 if the participant did not receive service from a College/Community College	1 = Yes 0 = No
If Other, please Specify	AN 2000	Text value of other co-enrollments
			86 Sales and Related Occupations 87 Office and Administrative Support Occupations 88 Farming, Fishing, and Forestry Occupations 89 Construction and Extraction Occupations 149 Installation, Maintenance, and Repair Occupations 150 Production Occupations 151 Transportation and Material Moving Occupations 152 Military Specific Occupations
Enrollment Comment	AN 2000	Record Enrollment Comment
Signature of director or authorized representative	AN 100	Record signature of director or authorized representative CMS System Name: "Witnessed By"
Number in Family (Recert)	IN 2	Record Number in Family (Recert)
Signature of Participant (Applicant signed the applicant certification on (Recert))	IN 1	Record 1 if Applicant signed the Applicant Form at recertification Record 0 if Applicant did not sign the Applicant Form at recertification	1 = Yes 0 = No
Signature of director or authorized representative at recertification	AN 100	Record signature of director or authorized representative at recertification CMS System Name: "Witnessed By"
Recerfication Comment	AN 2000	Record recertification comments
Specify Public Assistance Recipient	AN 225	If applicant is receiving or has received public other public assistance, specify other public assistance recipient
Last Updated Date	DT 8	System-generated	YYYYMMDD
Address Line 1 (Mailing address (if changed)	AN 225	Record participant mailing address if changed from enrollment address 1
Address Line 2	AN 225	Record participant mailing Address Line 2 if changed from enrollment address 2
City	AN 225	Record participant mailing address City if changed from enrollment address city
State	AN 2	Record participant mailing address State if changed from enrollment address State
Zip	IN 5	Record participant mailing address Zip if changed from enrollment address zip	00000
Phone number	IN 10	Record participant phone if changed from enrollment phone
Public Burden Statement (1205-0040)
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondent’s reply to these reporting requirements is mandatory (Older Americans Act Reauthorization Act of 2016 and Workforce Innovation and Opportunity Act, Section 116). Public reporting burden for this collection of information is estimated to average 12 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 Workforce Investment ● U.S. Department of Labor ● Room C-4510 ● 200 Constitution Ave., NW, ● Washington, DC ● 20210. Do NOT send the completed application to this address.

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Sheet 2: System Element

Form No.	DATA ELEMENT NAME	DATA TYPE/ FIELD LENGTH	DATA ELEMENT DEFINITIONS/INSTRUCTIONS	CODE VALUE
NEW	Sub-Recipient Organization Name	AN 225	Record sub-recipient organization name
NEW	Address1	AN 225	Record sub-recipient organization address 1
NEW	Address2	AN 225	Record sub-recipient organization address 2
NEW	Work Phone	IN 10	Record the user's work phone
NEW	Role	AN 26	Record the user's Role
NEW	Supervisor	AN 26	Record the user's Supervisor
NEW	Fax Number	IN 10	Record the user's fax number

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Sheet 3: Participant Job Codes

Participant Job Codes

Management

Business and Financial Operations

Computer and Mathematical

Architecture and Engineering

Life, Physical, and Social Science

Community and Social Services

Legal

Education, Training, and Library

Arts, Design, Entertainment, Sports, and Media

Healthcare Support

Protective Service

Food Preparation and Serving Related

Building and Grounds Cleaning and Maintenance

Personal Care and Service

Sales and Related

Office and Administrative Support

Farming, Fishing, and Forestry

Construction and Extraction

Installation, Maintenance, and Repair

Production

Transportation and Material Moving