ETA-9104 Quarterly Report Form

F. Quarterly Report Form

OMB Approval No. 1205-0439

Expiration date: 01/31/07

Grantee:

Grant Number:

Project Type:

Project ID:

Project Name:

Project Quarter:

Performance Period Covered by this Report: ____________ through ___________

PERFORMANCE FACTOR	REGULAR or DISASTER Workforce Dev.	DISASTER Temporary Jobs	DUAL ENROLLMENT	TRADE ACT HEALTH INSURANCE
TOTAL PARTICIPANTS
Receiving Intensive Services
Enrolled in NEG-funded Training
Receiving NEG-funded Supportive Services
Receiving Needs-Related Payments
Employed in Temp. Disaster Relief Asst.
Receiving Health Coverage Payments
Exits
Entering Employment at Exit
TOTAL EXPENDITURES: GRANTEE LEVEL
NRPs
Supportive Services
Health coverage Payments
Program Management and Oversight
- Administration, excl. NRP/Premium Payment Processing
- NRP Processing
- Premium Payment Processing
- Other
Indirect
Health Coverage Payment Admin.
Other
TOTAL EXPENDITURES: PROJECT OPERATOR LEVEL
Participant Wages
Participant FBs
Core and Intensive Services
NEG-funded Training
NEG-funded Supportive Services
NRPs
Project Management and Oversight
- Administration, excl. NRP Processing
- Other
Other
TOTAL EXPENDITURES: GRANTEE AND PROJECT OPERATOR

Comments: ________________________________________________________________________________________

ETA 9104

The reporting requirements are approved by OMB according to the Paperwork Reduction Act of 1995 under OMB approval No. 1205-0439. NOTE: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondent’s obligation to reply to these reporting requirements are mandatory (PL: 107-210). Public reporting burden for this collection of information is estimated at 30 minutes. Send comments regarding the burden estimate or any other aspect of this collection, including suggestions for reducing this burden to the U. S. Department of Labor, Office of National Response, Room N-5422, Washington D.C. 20210. (Paperwork Reduction Project 1205-0439).