United States 

## ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460 Form Approved
OMB No. 2050-0192 Expires 07-31-2009

JOB TRAINING REPORTING FORM
Brownfields

PART I – GRANT RECIPIENT INFORMATION

1. Grant Recipient Name

2. Grant Number Public reporting burden for this collection of information is estimated to average 5 hours per response, including the time for reviewing instructions, searching 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 of information, in cluding suggestions for reducing
this burden, to the Environment al Protection Agency, Office of Environmental Information, Code 2822T, Washington, DC 20460 and to the Paperwork Reduction Project, Office of Management and Budget, Washington, DC 20503. DO NOT RETURN your form to either of these addresses. Send your completed form to the address provided by the issuing

office. PART II – PERFORMANCE MEASURES INFORMATION
Table A – Mandatory Performance Measures

Measure (a) This Quarter (b) Cumulative

3. Number of Participants Completing Training

4. Number of Participants Obtaining Employment

5. Average Hourly Wage of Participants Obtaining Employment

6. Funds Leveraged (total)

6-1. Funding Source Name

6-2. Activity Funded

6-1. Funding Source Name

6-2. Activity Funded

6-1. Funding Source Name

6-2. Activity Funded

7. Supplemental Performance Measures Information (optional)

PART III – APPROVALS 8. Grant Recipient Project Manager

Name Signature Date

9. US EPA Regional Representative

Name Signature Date

EPA Form 6200-04 (9-2006)EPA Form 6200-04 (9-2006) INSTRUCTIONS FOR COMPLETING

JOB TRAINING REPORTING FORM - BROWNFIELDS

GENERAL INSTRUCTIONS

Overview: As specified in your grant terms and conditions, all j ob training grant recipients must report to EPA on a regular basis. This OMB and EPA approved re porting form (OMB No. 2050 - 0192, EPA Form 6200-04), supplements your Quarterly Reports with informati on about specific activities and accomplishments that EPA deems necessary to adequately monitor and evalua te the performance of jo b training grants. Please contact your EPA Regional represen tative if you have any questions when completing this form. Please note that, in most instances, all repor ted information is accessible by the public under the Freedom of Information Act (FOIA) and may be di stributed by EPA to the public unless one of the FOIA exclusions is applicable.

Compared to the Quarterly Reports, the Brownfie lds Job Training Reporting Form (JT Reporting form) contains quantitative information re lating to four specific measures of grant recipient performance. Reporting on these specific activities and accomplishments must be provided in the attached JT Reporting form rather than in the Quarterly Reports. Add itional voluntary and/or narrative information may be provided in Part II of this fo rm or in the Quarterly Report.

When to Submit: Original JT Reporting Forms. Grant recipients must develop the fi rst JT Reporting form when the first specified accomplishment has occurred (e.g., when the firs t class of trainees “graduates” from the training program provided under the grant, or when levera ged funding is committed to supplement the grant activities). The form should be attached and deliver ed with the next required Quarterly Report.

Updated JT Reporting Forms. JT Reporting forms should be up dated and delivered as additional accomplishments occur, and should be attached to the next required Quarterly Report. In addition, an updated form should be provided when the grant is being closed-out.

To Whom to Submit: Grant recipients must submit JT Reporting Forms to th eir EPA Regional Representative identified in the terms and conditions of the cooperative agreement. Th e EPA Regional Representative may request the form also be submitted to the EPA Headquarters Data Ma nager. When online submission is available and JT Reporting Form information is entered online the data will automatically be delivered to the EPA Regional Representative.

How to Submit: EPA is undertaking a two-phased process to facilitate electronic reporting and provide an information dissemination system to facilitate future grant recipi ent reporting. EPA will prepare electronic versions of this and other required reporting forms for the grant reci pients to complete and submit via e-mail. When the Assessment, Cleanup, and Redevelopment Exchange Sy stem, (ACRES) is availa ble on online to grant recipients, JT Reporting Form inform ation may be entered electronically into the web-based database. Electronic reporting is optional; hard c opy reports will always be acceptable.EPA Form 6200-04 (9-2006) DETAILED INSTRUCTIONS FOR CO MPLETING EACH ITEM ON FORM

PART I - GRANT RECIPIENT INFORMATION

1. Grant Recipient Name. Enter the grant name. Use the official name of the grant recipient as provided in the cooperative agreement, unless otherwise directed by the EPA Regional Representative.

2. Grant Number. Enter the grant number. Use the number of the grant as provided in the cooperative

agreement.

PART II - PERFORMANCE MEASURES INFORMATION

This section contains two parts—one mandatory, for certain limited performance measures information (Table A); the other optional, for narrative information to supplement the quantitative information provided (section 7).

Table A - Mandatory Performance Measures. In Table A, provide all quantitative information relating to each of the four (4) mandatory perf ormance measures. For each measure, enter amounts in column (a) – This Quarter – to reflect the incremental accomplishmen ts attained during the curre nt reporting quarter and column (b) – Cumulative – to reflect the total accomplishmen ts attained to date during the term of the grant. Note: Quantitative information relating to these perf ormance measures should only be provided in the table (i.e., not in narrative repo rting contained in the Quarterly Report).

3. Number of Participants Completing Training. Enter the number of participants taking the grant funded training who have comple ted the training program.

4. Number of Participants Obtaining Employment. Enter the number of graduates from the grant funded training program who have obtained employment of any kind. Self-emp loyed graduates should be included

in this count. The cumulative total nu mber inserted in column (b) should only increase during the term of the grant; the grant recipients’ quantitative reporting of th e cumulative total should not reflect any decreases for graduates who had obtained employment , but later report losing their jobs. If desired, provide a brief narrative description in section 7 for any reported job losses.

5. Average Hourly Wage. Enter the average hourly wage of job training graduates in their initial posttraining employment. Provide the hourly wage for the first job that each employed graduate secures after completing the job training program. Anecdotal informa tion about subsequent jobs and wages may also be narratively provided by the grant recipient.

6. Funds Leveraged. Enter the total amount of funding leveraged as a result of grant activ ities. Capture the total number of non-grant dollars linke d and leveraged to support additional, related activitie s of the grant recipient. To be reportable, there must be a de monstrable link or connection between the EPA funded activity and the leveraged funding. Funding can occur through direct financial assistance and/or through inkind services or supplies. Usually , leveraged funding that was committe d prior to the award of the EPA grant should not be reported as leveraged since the ac tivity predates the award. In addition, leveraged funding should not be reported in this section until the funding has been committed. These leveraged funds may be used to support activities th at cannot be funded by the EPA grant (e.g., transportation or child care for job training students).EPA Form 6200-04 (9-2006) In addition to the total leveraged funds, also describe the source and amount of funding leveraged, and the types of activities it funded. For each funding source (6-1 ), also list the type of activity funded (6-2) and the amount of funding leveraged per source in columns (a) and (b). As necessary, add additional lines for 6-1

and 6-2.

6-1. Funding Source Name(s). For each funding source, enter the name of the organization providing the funds and/or in-kind services. Examples of sources of leveraged funding include other EPA programs, private organizatio ns, state environmental, labor, or economic agencies, tribal governments, local governments (including community development corporati ons), and other federal agencies.

6-2. Activity Funded. For each funding source listed under 6-1, provide th e type of activity that was supported. Examples of leveraged activities include additional curric ula development/training (e.g., environmental and non-environm ental), supplies/equipment, tr ansportation for students, and

child care for students.

7. Supplement Performance Measures Information (Optional). Provide a brie f narrative description to supplement the required performance measures reporti ng, including, for example: demographic information (e.g., gender, age, ethnicity, education) ; description of the training curricul a; information on the types of jobs obtained by the participants entering /completing the training; availabili ty of photographs/video footage of the training/graduation/post-training employment; and/or specific milest ones tracked by the grant recipient for its own management.

PART III - APPROVALS

8. Grant Recipient Project Manager. Type or print the name of the gr ant recipient project manager. The project manager should also sign and date the completed JT Re porting form before submission.

9. U.S. EPA Regional Representative. Type or print the name of the EPA Regional Representative. The EPA representative should also sign and date the reviewed JT Reporting form.