IHE Questionnaire

Paperwork Burden Statement
For IHE Staff
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless such collection displays a valid OMB control number. The
valid OMB control number for this information collection is xxxx-xxxx. The time required
to complete this information collection is estimated to average 2,875 hours per response for
the total number of respondents, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection.
If you have any comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: U.S. Department of Education,
Washington, D.C. 20202-4651. If you have comments or concerns regarding the status
of your individual submission of this form, write directly to: [insert program
sponsor/office], U.S. Department of Education, 600 Independence Avenue, S.W., [insert
building/room number], Washington, D.C. 20202-4651.

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National Center on Service Obligations – IHE Questionnaire
Scholar Personal Information

1.

Grant award number

-- None --

Scholar Identifying Information

2.

Scholar name
First Name

Middle Name

Maiden Name, if applicable

Last Name

3.

Scholar Social Security number

4.

What is the scholar's date of birth?

mm-dd-yyyy

Scholar Contact Information

5.

Scholar primary address and contact information
Address Line 1

Address Line 2

City

State

Zip Code

Phone

E-mail Address

2

Verify E-mail Address

Fax

6.

Scholar secondary address and contact information
Address Line 1

Address Line 2

City

State

Zip Code

Phone

E-mail Address
Verify E-mail Address

Fax

7.

Address and contact information for a relative or other person through which NCSO may contact the scholar, if necessary.
Contact Salutation

Contact First Name

Contact Middle Name

Contact Last Name

Primary Address Line 1

Primary Address Line 2

Primary City

Primary State

Primary Zip Code

Primary Phone

Primary E-mail Address

Primary Fax

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Secondary Address Line 1

Secondary Address Line 2

Secondary City

Secondary State

Secondary Zip Code

Secondary Primary Phone

Secondary E-mail Address

Secondary Fax

Program and Obligation Information

8.

Scholar special education training area:
Check all that apply.
General special education, cross-categorical, generic, multicategorical, or noncategorical
General special education, mild or moderate
Low-incidence disabilities/multiple disabilities/severe disabilities
Combined studies: General education and special education
Developmental delay
Specific learning disabilities
Speech/language impairment
Emotional disturbance/behavioral disorders
Autism
Traumatic brain injury
Deafness and/or hard-of-hearing
Visual impairment and/or blindness
Deaf-blindness
Mental retardation: Mild/moderate
Mental retardation: Severe

4

Other health impairment
Physical impairment/orthopedic impairment
Adapted physical education
Assistive technology
Bilingual special education/ESL/TESOL
Early childhood/early intervention
Inclusive/collaborative practices
Special education for youth in correctional facilities
Transition
Other, please specify

9.

Scholar services training area:
Check all that apply.
Audiology
Counseling
Educational diagnostician
Interpreter/ASL
Music therapy
Nursing
Occupational therapy
Orientation & mobility
Paraprofessional/Teacher Assistant/Teacher Aide
Physical therapy
Rehabilitation counseling
School counseling
Psychology
Speech/language
Social work

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Therapeutic recreation
Work experience coordinator (employment transition specialist)
Other, please specify

10. Scholar program exit or graduation/completion status.*
Check all that apply.

The scholar graduated/completed the program
The scholar exited the program without graduating/completing
The scholar is still enrolled in the program, but is no longer receiving OSEP funding
because:
The grant ended
Other
Please specify other reason scholar is no longer receiving OSEP funding

Please enter the date of exit/graduation/completion if applicable. (No date required if scholar is still enrolled in the program)

mm-dd-yyyy

11. Length of obligation (months)

12. Amount of obligation (dollars)

13. For what reason(s) did this scholar leave the program before completion?
Check all that apply.

Transferred to another training program in special education or related services
Transferred to another program not in special education or related services
Financial stress or burden
Health (physical/emotional) of self or family member
Moved

6

Obtained employment
Other personal reasons
Poor academic performance
Poor practicum/field-based performance
Other, please specify

Education and Demographic Information

14. Check the degree(s) or certificate(s) or endorsement(s) the student held when he/she entered this grant-supported training.
Check all that apply.

High School Diploma or Equivalency
Associate Degree
Bachelor’s Degree
Master’s Degree
Educational Specialist
Doctoral Degree
Post-doctoral Degree
State or Professional Credential/Certificate
State-issued Endorsement
Grantee-issued Endorsement

15. Check the degree(s) or certificate(s) or endorsement(s) the student received as a result of completing this grant-supported training.
Check all that apply.

Bachelor’s Degree
Master’s Degree
Educational Specialist
Doctoral Degree
Post-doctoral Degree
State or Professional Credential/Certificate

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State-issued Endorsement
Grantee-issued Endorsement
Other, please specify

16. What is the scholar's gender?
Female

Male

17. Is the scholar unable to continue a course of study or perform the service obligation because of a permanent disability?
Yes

No

18. Which of the following best describes the scholar? Please select one or more.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other, please specify

19. Is the scholar Hispanic or Latino?
Yes

No

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IHE Contact Information Update

IHE contact update
Below is information NCSO has for your University and grant officer. Please update any fields with an asterisk (*) as necessary.

1.

College/University Name*

2.

Division Name

3.

College/University Address and Contact Information*
Address Line 1

Address Line 2

City

State

Zip Code

Phone

Mobile Phone

E-mail Address

Alternative E-mail

TTY

Fax

4.

Grant Officer Information*
First Name

Last Name

Title

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Number of Hours Spent on Project
Annually
Address Line 1

Address Line 2

City

State

Zip Code

Phone

Mobile Phone

Fax

TTY

E-mail Address

Alternative E-mail Address

5.

Grant Award Number
Grant #1
Grant #2

6.

Project Title (Name of your institution’s application)

7.

Program Beginning Date

mm-dd-yyyy

8.

Program Ending Date

mm-dd-yyyy

9.

Is this grant a No Cost Extension?
Yes
No
If yes, what was the start date of the no cost extension?
mm-dd-yyyy

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