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


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
or services used
(a) Remedial/Basic Skills
Other Support Services
(b) Bi-Lingual Skills
(g) Counseling
High School/GED Courses
(h) Leadership Skills
(d) Post Secondary Assistance
Job Interview Skills
(e) Vocational Skills
Job Placement Skills
Total number of hours and percent time spent by the participant on education and support services:
Percent educational hours to total program hours:___________________
Number of hours spent on construction work-site by the participant:
Percent construction hours to total program hours:___________________
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)


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