Exit Information
SSAI SCSEP Exit Form
OMB Approval Number: 1205-‐0040 Expiration Date: Not Applicable
Fields marked with w indicate a data validation field. You must secure acceptable validation documentation. See the SSAI Data Validation Checklist for further instructions. Shaded areas indicate data fields that are optional.
Exit Information 1. Name of participant: ______________________________________________________ 2. PID: _____________________________
Participant ID Number assigned by SPARQ
3. Participant mailing address (if changed) ______________________________________________________________________________________________________________________________ a. Number and Street, Apt. Number; or PO Box ______________________________________________________________________________________________________________________________ b. City c. County ______________________________________________________________________________________________________________________________ d. State e. ZIP Code 4. Phone number of participant (if changed) ______________________________________________________________________________ 5. Exit due to unsubsidized placement? (Select one only) Complete unsubsidized placement form if you answer “yes” to this question. i. Yes, regular employment ii. Yes, self-‐employment iii. No
Authorized for Local Reproduction
ETA-‐9123 (Revised February 2015; replaces prior versions)
This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-‐0040. 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 109-‐365 Sec 501-‐518) 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 20210 (PRA Project 1205-‐ 0040). Participant Name ________________________________________________________________________________________________________________ Last First Middle
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SSAI SCSEP Exit Form
OMB Approval Number: 1205-‐0040 Expiration Date: Not Applicable
Fields marked with w indicate a data validation field. You must secure acceptable validation documentation. See the SSAI Data Validation Checklist for further instructions. Shaded areas indicate data fields that are optional.
6. If exit is not due to unsubsidized employment, other reason for exit (Select one only) i. Moved from area ii. For cause p iii. Voluntary iv. Non-‐income eligible p
v. Durational limit p
vii. Deceasedw
viii. Health/medicalw w DV TIP: Self-‐attest or 3rd party attest; or 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 detailed case notes.
w DV TIP: Death record or certification; or death notice published through the Internet, in newspaper, and local funeral homes or 3rd party attestation, or detailed case notes.
ix. Family carew
w DV TIP: Self-‐attest or 3rd party attest form; or 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 detailed case notes.
p
x. Institutionalizedw w DV TIP: Self-‐attest or 3rd party attest form; or 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 detailed case notes. Indicates type of exit that requires 30-‐day written notice be provided to participant before exit.
6a. Non-‐exit reasons for closing the record (Select one only) i. Withdrew application prior to assignment/withdrew from waiting list ii. * Transferred to another project (specify other grantee’s code) _____________________________ iii. * Moved to another sub-‐grantee (specify sub-‐grantee code) _________________________________ iv. Dual Enrollment (with another SCSEP grantee)
* No data entry in SPARQ. Field is system-‐generated Participant Name ________________________________________________________________________________________________________________ Last First Middle
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SSAI SCSEP Exit Form
OMB Approval Number: 1205-‐0040 Expiration Date: Not Applicable
Fields marked with w indicate a data validation field. You must secure acceptable validation documentation. See the SSAI Data Validation Checklist for further instructions. Shaded areas indicate data fields that are optional.
6b. Date of termination letter _________ (MM/DD/YYYY)
wDV TIP For all exits involving involuntary exits (30 days before exit letter) letter must exist with date of termination. Document used to verify (self-‐attest form, standardized or literacy test results, detailed case notes, other)
7. Date of exit or other closing of record ____________________________________ (MM/DD/YYYY) w w DV TIP #7. To validate the date of exit, you can use subgrantee records such as: payroll records, termination letter; the signature on the Exit waiver of confidentiality (if applicable) or detailed case notes. 7a. Will participant engage in volunteer work after participation? Yes No Unknown Check “yes” if the participant intends to engage in any volunteer work – formal or informal – after exiting SCSEP. Formal volunteer work means activities or work that participants perform for a public agency of a State, local government or intergovernmental agency, or for a charity or similar non-‐profit organization, for civic, charitable, or for humanitarian reasons, and without expectation of compensation. Informal volunteer work is defined as volunteering that an individual performs on his or her own, not through an organization. If yes, number of activities: _____________ For Formal Volunteering: For activities, enter the total number of organizations for which the participant volunteers. Count separate organizations, not jobs within each organization. For Informal Volunteering: For activities count the number of discrete volunteer activities in which the participant will engage. For example, if the participant teaches sewing to neighborhood girls in her own home and also does shopping and housekeeping for free for a disabled neighbor, count the sewing class as one activity and the assistance to the neighbor as a second activity and input 2 on the form.
Participant Name ________________________________________________________________________________________________________________ Last First Middle
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SSAI SCSEP Exit Form
OMB Approval Number: 1205-‐0040 Expiration Date: Not Applicable
Fields marked with w indicate a data validation field. You must secure acceptable validation documentation. See the SSAI Data Validation Checklist for further instructions. Shaded areas indicate data fields that are optional.
Waiver of Confidentiality (applicable only to participants who exit into unsubsidized employment)
I, ___________________________________________________________, hereby authorize _________________________________________________________________ [name of participant] [name of employer] to release to ____________________________________________________________________________ information regarding my employment status [name of sub-‐grantee] and wages for a period of thirteen months from the date below. This information may be used solely for statistical purposes and may not be disclosed to anyone not connected with the Senior Community Service Employment Program (SCSEP) in a manner that is individually identifying. 8. Signature of participant __________________________________________________________________________________________________ (only have participant sign if they are exiting for unsubsidized placement and execute confidentiality waiver above; otherwise, leave blank) 9. Date of signing _______________________________ (MM/DD/YYYY) (applies to #8 above only otherwise leave blank).
9a. Exclusion discovered after exit. w (applies only to participants who initially exited for reasons other than unsubsidized employment) i. Deceased w w DV TIP: 3rd 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 w w DV TIP: Self-‐attest or 3rd party attest form; or 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 detailed case notes.
iii. Family carew
w DV TIP: Self-‐attest or 3rd party attest form; or 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 detailed case notes.
Participant Name ________________________________________________________________________________________________________________ Last First Middle
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SSAI SCSEP Exit Form
OMB Approval Number: 1205-‐0040 Expiration Date: Not Applicable
Fields marked with w indicate a data validation field. You must secure acceptable validation documentation. See the SSAI Data Validation Checklist for further instructions. Shaded areas indicate data fields that are optional.
iv. Institutionalized w w DV TIP: Self-‐attest or 3rd party attest form; or 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 detailed case notes.
9b. Date exclusion occurred ______________________________________________________________________________ (MM/DD/YYYY)
(Exclusion date must be on or after the date of exit, #7 above).
10. Exit comments – detailed case note sectionw 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: _______________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
Volunteer Information
11. Name of primary volunteer activity_______________________________________________________________________________ • Enter the name of the organization with which the participant is volunteering. If the participant is volunteering with more than one organization, enter the name of the organization where the participant will spend the most hours per quarter. • If the participant is doing informal volunteer work on his/her own, and not through an organization, enter “informal” above.
Participant Name ________________________________________________________________________________________________________________ Last First Middle
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SSAI SCSEP Exit Form
OMB Approval Number: 1205-‐0040 Expiration Date: Not Applicable
Fields marked with w indicate a data validation field. You must secure acceptable validation documentation. See the SSAI Data Validation Checklist for further instructions. Shaded areas indicate data fields that are optional.
12. Activity conducted in:
Not-‐for-‐profit organization Government organization
Faith-‐based organization Informal; no organization
• If the participant is engaging in formal volunteer work, indicate whether that work is with a not-‐for-‐profit organization, faith-‐based organization, or a government organization. You may only select one type of organization. If the participant is volunteering with a faith-‐based organization, select that option rather than “not-‐for-‐profit” organization. • If the participant is not volunteering through an organization, select “Informal, no organization.”
13. Is this activity conducted in a SCSEP host agency?
Yes
No
• Indicate if the participant is volunteering with an entity that is a current host agency (after exit). Talk with the participant first as it is likely that he/she may be volunteering for the host agency with which they used to be assigned. If you do not know whether the entity is a SCSEP host agency, select “no.” • Remember a participant may not volunteer at his/her host agency at any time or in any capacity while enrolled on SCSEP.
14. Number of hours per week participant expects to volunteer in this activity: __________________
• Enter the total number of hours that the participant has volunteered or expects to volunteer in an average quarter. You may estimate the number based on the number of hours the participant has previously volunteer in an average week or month.
• You may enter the time in half-‐hour increments. Use normal rounding rules; anything .75 or higher is rounded up; anything less than .25 is rounded down.
15. Total number of volunteer activities_____________ • If the participant is volunteering through an organization (formal volunteering), enter the total number of organizations for which the participant is volunteering after exit. Count separate organizations, not jobs, within each organization.
• If the participant is engaging in informal volunteer work and is not volunteering through an organization, count the number of discrete volunteer activities in which the participant engages. For example, if the participant teaches sewing to neighborhood girls in her own home and also does shopping and housekeeping for a disabled neighbor, count the sewing classes as one activity and the assistance to the neighbor as a second activity, entering 2 in the blank above.
Participant Name ________________________________________________________________________________________________________________ Last First Middle
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SSAI SCSEP Exit Form
OMB Approval Number: 1205-‐0040 Expiration Date: Not Applicable
Fields marked with w indicate a data validation field. You must secure acceptable validation documentation. See the SSAI Data Validation Checklist for further instructions. Shaded areas indicate data fields that are optional.
16. Follow-‐up (to confirm participant is still volunteering) a. *Scheduled date ________________________________ (MM/DD/YYYY) b. Completed date _________________________________ (MM/DD/YYYY) c. Engaged in volunteer work? Yes No * No data entry in SPARQ. Field is system-‐generated.
Participant Name ________________________________________________________________________________________________________________ Last First Middle
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