1. For the Participant’s most recent (or current) job, please complete the following: Name of employer_______________________________________________ Job Title________________________________________________________ Hourly Wage ____________________________ Dates of Employment: From ______________________________ To: _____________________________ Multi-State Advanced Manufacturing Consortium (M-SAMC) Participant Intake Form Page 1 First Name Middle Initial Last Name Contact Information Address CityStateZip Code Home Phone Cell Phone Social Security # Student ID # Participant Information Date of Birth GenderMale Female EthnicityHispanic/Latino Non-Hispanic/Latino Race (check all that apply)Native American/AlaskanBlack/African American AsianWhiteNative Hawaiian/Pacific Island Highest Level of Education AttainmentGEDHS Diploma Some CollegeAssociate’s DegreeBachelor’s Degree or Higher Check all that apply (see definitions on next page if needed) Eligible for Veteran’s Benefits Currently Employed Individual with a Disability Eligible for TAA Benefits Eligible for Pell Grant Beginning Semester Program of Study Program Information Type of Degree or Certificate EnrollmentFull-time StatusPart-time Email Address M-SAMC Participant Intake Form 20141024 v 002.pdf Page 1 of 3

2. Multi-State Advanced Manufacturing Consortium (M-SAMC) Participant Intake Form Page 2 Equal Opportunity is the Law: It is against the law for this recipient of Federal financial assistance to discriminate on the following bases: against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief; and against any beneficiary of programs financially assisted under Title I of the Workforce Investment Act of 1998 (WIA), on the basis of the beneficiary's citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIA Title I-financially assisted program or activity. The recipient must not discriminate in any of the following areas: deciding who will be admitted, or have access, to any WIA Title I-financially assisted program or activity; providing opportunities in, or treating any person with regard to, such a program or activity; or making employment decisions in the administration of, or in connection with, such a program or activity. What To Do If You Believe You Have Experienced Discrimination If you think that you have been subjected to discrimination under a WIA Title I-financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either: the recipient's Equal Opportunity Officer (or the person whom the recipient has designated for this purpose): INSERT CONTACT NAME AT YOUR COLLEGE or the Director, Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue NW, Room N-4123, Washington, DC 20210. If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center (see address above). If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient). If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action. Veteran’s Priority: In compliance with the Jobs for Veterans Act of 2002, it is the responsibility of the public workforce system to provide priority of service to all veterans and eligible spouses who receive services under any qualified job training program funded in whole or in part by the U.S. Department of Labor (DOL). This means Veterans and eligible spouses may be moved to the front of waiting lists or served first prior to non-covered individuals in any service using Federal DOL funds. Veterans should inform program staff immediately of their veteran status. Participant Information: In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Labor is authorized to collect information to implement the Trade Adjustment Assistance Community College and Career Training Program under 19 USC 2372 – 2372a. The principal purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. Providing this information, including a social security number (SSN) is voluntary; failure to disclose a SSN will not result in the denial of any right, benefit or privilege to which the participant is entitled. The information collected on this form will be retained in the program files of the grantee and may be released to other Department officials in the performance of their official duties. I attest that the information I have provided on the preceding page is to the best of my knowledge complete and accurate, and I hereby acknowledge that I have received and reviewed a copy of the College’s EO policy, Veterans Priority and grievance procedure, understand these policies and have been informed of my rights related to these policies, have been given the opportunity to have my questions answered regarding these policies. Student Signature: ________________________________________________ Date: ____________________________ Your Rights M-SAMC Participant Intake Form 20141024 v 002.pdf Page 2 of 3

3. Definitions Equal Opportunity Legislation and Regulations: Section 504 of the Rehabilitation Act of 1973 The purpose of this part is to effectuate Section 504 of the Rehabilitation Act of 1973, and amended by the Rehabilitation Act Amendments of 1974which is designed to eliminate discrimination on the basis of handicap in any program or activity receiving Federal financial assistance. Title IX, Age Discrimination Act of 1975 It is the purpose of this chapter to prohibit discrimination on the basis of age in programs or activities receiving Federal financial assistance. Pursuant to regulations prescribed under section 6103 of this title, and except as provided by section 6103(b) of this title and section 6103(c) of this title, no person in the United States shall, on the basis of age, be excluded from participation, in be denied the benefits of, or be subjected to discrimination under, any program or activity receiving Federal financial assistance. Section 188 of the Workforce Investment Act of 1998 Federal financial assistance for the purpose of applying the prohibitions against discrimination on the basis of age under the Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.), on the basis of disability under section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), on the basis of sex under title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), or on the basis of race, color, or national origin under title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), programs and activities funded or otherwise financially assisted in whole or in part under this Act are considered to be programs and activities receiving Federal financial assistance. No individual shall be excluded from participation in, denied the benefits of, subjected to discrimination under, or denied employment in the administration of or in connection with, any such program or activity because of race, color, religion, sex (except as otherwise permitted under Title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), national origin, age, disability, or political affiliation or belief. Eligible for Veteran’s benefits: A person is considered eligible for Veteran’s benefits and Veteran priority of service if they meet one of the following conditions: 1.Is a person who served on active duty in the armed forces for a period of less than or equal to 180 days, and who was discharged or released from such service under conditions other than dishonorable. 2.Is a person who served on active duty for a period of more than 180 days and was discharged or released with other than a dishonorable discharge; or was discharged or released because of a service connected disability; or as a member of a reserve component under an order to active duty pursuant to section 12301 (a), (d), or, (g), 12302, or 12304 of Title 10, U.S.C., served on active duty during a period of war or in a campaign or expedition for which a campaign badge is authorized and was discharged or released from such duty with other than a dishonorable discharge; or 3.Is a person who is (a) the spouse of any person who died on active duty or of a service-connected disability, (b) the spouse of any member of the Armed Forces serving on active duty who at the time of application for assistance under this part, is listed, pursuant to 38 U.S.C 101 and the regulations issued thereunder, by the Secretary concerned, in one or more of the following categories and has been so listed for more than 90 days: (i) missing in action; (ii) captured in the line of duty by a hostile force; or (iii) forcibly detained or interned in the line of duty by a foreign government or power; or (c) the spouse of any person who has a total disability permanent in nature resulting from a service-connected disability or the spouse of a veteran who died while a disability so evaluated was in existence. Employed: A person who works for pay. Individual with a disability: Individual who has a physical or mental impairment that substantially limits one or more of the person's major life activities. Eligible to receive a Pell grant: A person is considered eligible to receive a Pell grant if they can demonstrate “sufficient financial need” and are enrolled in an eligible college. The guidelines for “sufficient financial need” are complex, so eligibility is determined by filing a Free Application for Federal Student Aid (FAFSA). Eligible to receive TAA benefits: A person is eligible to receive Trade Adjustment Act (TAA) benefits if they are a dislocated worker (see above) who previously worked for an employer whose closure or layoffs were certified by the U.S. Department of Labor to have been caused by foreign competition. People generally find out whether they are eligible for TAA benefits from their prior employer, their union, or a One-Stop workforce center. Participant Intake Form Page 3 – Definitions and Background Multi-State Advanced Manufacturing Consortium (M-SAMC) M-SAMC Participant Intake Form 20141024 v 002.pdf Page 3 of 3

4. Multi-State Advanced Manufacturing Consortium (M-SAMC) Participant Intake Form - Instructions for Administrators Purpose. This intake form collects information from students that is either unattainable from other locations or intends to verify crucial identifying information. It is also required that Participants be provided key Equal Opportunity (EO), Veterans and other information, be made aware that certain information will be retained and utilized by program and Evaluation staff and that they acknowledge being informed of these policies and procedures. Overview. Your college has joined a group of other community colleges to form a consortium with the joint mission of improving manufacturing education. The US Department of Labor (USDOL) has awarded the consortium a Trade Adjustment Assistance Community College and Career Training (TAACCCT) grant to fund this mission. A requirement of USDOL is to evaluate the performance of the grant. Timeframe. The grant implementation period begins January 1, 2013 and concludes December 31, 2016. The intake form should be administered to program participants during this timeframe. The evaluation period officially concludes November 14, 2017. Data Security. The data used in the evaluation is considered private and will not be shared with any individuals or entities not involved in the evaluation. All data will be safeguarded using legally required means for securing and encrypting records. All evaluation data will be destroyed within fifteen (15) days after the conclusion of the evaluation period. Who completes the intake form? Anyone who has declared a program of study targeted under the grant Anyone who has taken a “major course” in the targeted program of study or an elective redesigned/created under the grant since January 1, 2013 When do students fill out the form? At the beginning of each term Note: Students only need to complete the form once. If a student has completed the form in another class or during a previous term, it does not need to be completed again by that student. Who administers the form? Course instructors or M-SAMC Implementation Facilitators Are students required to complete the form? No, students may choose not to fill out the form. However, they are encouraged to do so. Even if the student does not fill out the form, he/she will still be considered a participant in the grant. Administration of the intake form. Students may complete the form or a staff person may complete with the student. Please review the material on Page 2, provide a copy of Pages 2 and 3 to the participant for their records and secure participant signature at the bottom of Page 2. Once the form has been administered, please collect all completed forms and ensure that they are given to the college’s Implementation Facilitator. Any questions about the form or evaluation may be directed to Chris Spence, Lead TAACCCT Impact Evaluator, New Growth Group, LLC, 216-767-6262, cspence@newgrowthplanners.com Instructions M-SAMC Participant Intake Form 20141024 v 002.pdf INSTRUCTIONS