Looking for a Hud Forms And Templates? Download it for free!

Youthbuild Program Reports

U.S. Department of Housing

and Urban Development

Part 14

Office of Community Planning

and Development

Participant Tracking Worksheet

Sensitive Information: The information collected on this form is considered sensitive and is protected by the Privacy Act. The Privacy Act requires that these records

be maintained with appropriate administrative, technical, and physical safeguards to ensure their security and confidentiality. In addition, these records should be

protected against any anticipated threats to ,their security or integrity which could result in substantial harm, embarrassment, inconvenience, or unfairness to any

individual on whom the information is maintained.

Section I: Entrance Report

(Complete this section when the participant enters the program.)

1. Participant Identification(Last Name)

(First Name)

(Middle Initial)

2. Social Security Number

3. Date of Birth (MM/DD/YY)

4. Date of Program Entry (MM/DD/YY)

5. Current Address: Street/City/State/Zip

6. Gender:

a. Male

7. Race/Ethnicity:

a. White (Not Hispanic)

b. Black (Not Hispanic)

c. Hispanic

b. Female

d. American Indian or Alaskan Native (Not Hispanic)

e. Asian/Pacific Islander

8. Highest Grade or Year of School Completed:

a. Less than 8

b. 8th Grade

c. 9th Grade

d. 10th Grade

e. 11th Grade

f. High School graduate/GED

9. Current Living Status:

a. Living with Family

b. Living alone

c. Living with Friends

d. Living in a Homeless Shelter

e. Living in a Halfway House

f. Living in a Work/Release Program

g. Other:(specify) ______________________________________________________________________________________________________

10. Current Employment Status:

a. Employed, Full-Time

b. Employed, Part-time

c. Unemployed

11. If employed, current hourly wage rate: 12. If employed, number of hours, on average, working during a week: 13. Total Family Income from all sources:

______________ Hours

14. Source of Referral to this Youthbuild Program:(Check all that apply)

a. Local JTPA Program

b. Local JOBS Program

c. Apprenticeship Program(specify) ________________________

d. Local Trade Union(specify) _____________________________

e. Education Institution

f. Local Housing Authority

g. State/local training program

h. Other(specify) ________________

15. How did the participant learn about the Youthbuild Program? (Check all that apply)

a. Friends

b. TV/Radio

c. City-wide Newspaper

d. Neighborhood Flyers or Newspaper

e. Shelter

f. Parole Officer

g. Neighbors

h. Other:(specify)

Section II: Participation Report

Educational and Support Services

Number of courses completed

16. Educational and Support Services

Number of courses completed

or services used

(a) Remedial/Basic Skills

_____________________

(f)

Other Support Services

_____________________

(b) Bi-Lingual Skills

_____________________

(g) Counseling

_____________________

(c)

High School/GED Courses

_____________________

(h) Leadership Skills

_____________________

(d) Post Secondary Assistance

_____________________

(i)

Job Interview Skills

_____________________

(e) Vocational Skills

_____________________

(j)

Job Placement Skills

_____________________

17.

Total number of hours and percent time spent by the participant on education and support services:

Hours:____________________

Percent educational hours to total program hours:___________________

18.

Number of hours spent on construction work-site by the participant:

Hours:_____________________

Percent construction hours to total program hours:___________________

19.

Total amount of hourly work-site wages paid to the participant:

$_________________________

Total amount of need-based stipends, if any, paid to the participant:

$_________________________

Previous editions are obsolete

form HUD-40201 (7/97)

Form Hud-40201 - Youthbuild Program Reports - U.s. Department Of Housing And Urban Development

Related Articles

Related forms

Related Categories