Scholar Training & Employment

Paperwork Burden Statement
Scholar Training and Employment
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 – Scholar Training and Employment Information

Scholar Verification

Grant award number

-- None -1.

This field will be pre-populated and scholars will not be able to modify it.

Scholar name
First Name

Middle Name

Maiden Name, if applicable

Last Name

2.

Scholar Social Security number

3.

Date of birth

mm-dd-yyyy

Obligation Information

4.

In the program in which you received this grant, were you trained in any of the following Special Education Service Areas?
Please check all that apply.

General special education, cross-categorical, generic, multi-categorical, or non-categorical
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

2

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
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
Secondary transition
Other, please specify

5.

In the program in which you received this grant, were you trained in any of these service areas?
Please check all that apply.

Audiology
Counseling
Educational diagnostician
Interpreter/ASL
Music therapy
Nursing
Occupational therapy

3

Orientation & mobility
Paraprofessional/Teacher Assistant/Teacher Aide
Physical therapy
Rehabilitation counseling
School counseling
Psychology
Speech/language
Social work
Therapeutic recreation
Work experience coordinator (employment transition specialist)
Other, please specify

6.

Scholar program exit or graduation/completion status.

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

7.

For what reason(s) did you leave the program before graduation/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

4

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

8.

Length of obligation (months)*

9.

Amount of obligation (dollars)*

Contact Information

10. Please provide your primary mailing address and contact information.*
Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Mobile Phone
E-mail Address
Verify E-mail Address

Alternative E-mail Address
Verify Alternative E-mail Address
TTY

5

Fax

11. Please provide a secondary mailing address and contact information.
This may include parent's address and phone number.

Address Line 1

Address Line 2

City

State

Zip Code

Phone

E-mail Address

Verify E-mail Address

Fax

12. Please provide a person through which NCSO can contact you.
Contact First Name

Contact Last Name
Relationship to You (parent, sibling,
etc.)
Address Line 1

Address Line 2

City

State

Zip Code

Phone

Mobile Phone

E-mail Address

Alternative E-mail Address

TTY

6

Fax

Current Status

13. Are you unable to continue a course of study or perform the service obligation because of a permanent disability?*
NOTE: If answered yes, will end survey and you must upload supporting documentation.
Yes

No

14. Are you currently or have you been enrolled as a full-time student since exiting or graduating from this grant-funded program?*
NOTE: If yes, the survey will end after you enter the completion date of your educational program and upload supporting documentation.
Yes

No

15. What was the start date of your most recent full-time degree or certificate program?
mm-dd-yyyy

16. When is your full-time enrollment scheduled to end?
mm-dd-yyyy

17. Are you currently or have you served on active duty in the military since your exit or graduation/completion from this grant-funded program?
NOTE: If yes, the survey will end after you enter the completion date of your service and upload supporting documentation.
Yes

No

18. When did your military service begin?
mm-dd-yyyy

19. When is this service scheduled to end?
mm-dd-yyyy

20. Are you currently or have you been a Peace Corps volunteer or in the Domestic Volunteer Service since exit or graduation/completion from this grantfunded program?
NOTE: If yes, the survey will end after you enter the completion date of your service and upload supporting documentation.
Yes

No

21. Type of volunteer service
Domestic Volunteer Service
Peace Corps
Other

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22. When did your volunteer service term begin?
mm-dd-yyyy

23. When is this service scheduled to end?
mm-dd-yyyy

8

Employment Information
The questions relating to your employment affect your obligation fulfillment status.
24. Does your current employment or previous employment fulfill your service obligation?
Yes

No

Employment Information
Please provide information about your jobs since completing your funded program that fulfill your service obligation. “Job” is defined as a specific task or occupation. It is
possible to have more than one job for one employer.

Questions marked in red do not affect your obligation fulfillment status.
These questions are for measuring performance of the programs at the Office of Special Education Programs.
25. Are you {highly qualified/qualified/fully certified} for this position under IDEA and/or No Child Left Behind? {Highly qualified/Qualified/Fully certified} for purposes of this
data collection means that you meet the state requirements, if there are requirements in your state, for certification/licensure for this position.
1. {Highly qualified/Qualified/Fully certified}
2. {Not highly qualified/Not qualified/Not fully certified}
3. This state does not have requirements for certification/licensure for this position.

Yes

No

Note: If the position is an elementary or secondary general education/special education teacher, you can be “highly qualified”; if the position is general education/special
education paraprofessional/aide or early intervention, early childhood or preschool paraprofessional/aide, you can be “qualified”; or if the position is
administrator/coordinator, for related or supportive services in a school setting, or for teacher, related services, or supportive services in early intervention, early
childhood, you can be “fully certified.”
For more information on the definition of Highly Qualified please click here.

26. When did this job begin?
Begin with your current or most recent employment. Please enter only jobs that fulfill your service obligation. NOTE: For additional jobs, the text will change to: “When did this employment begin?”

mm-dd-yyyy

27. When did this job end?
Leave blank if you are currently employed in this job.

mm-dd-yyyy

28.

Is this full time or part time employment?
Full Time
Part Time
This is a summer position
This position has summers off
On average, how many hours do you work per week at this job? Note, this will only appear of the scholar selects “Part Time.”

29.

30. Which one of the following best describes this position?
Classroom Teacher

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Instructional Specialist
Paraprofessional/Teacher Assistant/Teacher Aide
Supervision (including in the capacity of a principal)
Teaching at the Postsecondary Level
Research
Policy
Technical Assistance
Program Development
Administration
Other, please specify

31. Does this position serve students in any of the following Special Education Service Areas?
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

10

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

32. Does this position serve students in these service areas?
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

11

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

33. What type of organization is this?
Check all that apply.

Elementary School
Middle School
Junior High School
High School
Special School
College or University
Government Agency
Nonprofit Organization
Research/Policy Organization
Other, please specify

Employment Information

34. Describe the percentage of time working on job teaching or serving special education students for the current or most recent school year.
Less than 40%
40% -- 50%
51% -- 60%
61% or greater

35. Describe the percentage of special education students taught or served on this job for the current or most recent school year.
Less than 40%
40% -- 50%

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51% -- 60%
61% or greater

36. Describe the percentage of time spent performing work related to the training for which the scholarship was received under section 662 of IDEA over the past
year or most recent period of employment. (This question only asked if scholar indicates he or she is not a classroom teacher)
Less than 40%
40% -- 50%
51% -- 60%
61% or greater

Employer Information

37. Employer's name
i.e., name of school district, name of government agency

38. Department name
i.e., school name, government department

39. Employer organization address
Address Line 1

Address Line 2

City

State

Zip Code

Phone

Fax

TTY

E-mail Address

URL of homepage

40. Please provide the name of a supervisor at this job who can verify this employment information.

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First Name

Last Name

Title

41. Supervisor's business address
Check here if address is same as above and proceed to 38.
Address Line 1

Address Line 2

City

State

Zip Code

Phone

Mobile Phone

E-mail Address
Verify E-mail Address
Alternative E-mail Address

Fax

TTY

42. Please provide the name of a human resources manager at this job who can verify this employment information.
First Name

Last Name

Title

43. Human resources manager's business address
Check here if address is same as above and proceed to 40.
Address Line 1

Address Line 2

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City

State

Zip Code

Phone

Mobile Phone

E-mail Address

Alternative E-mail Address

Fax

TTY

Position Change Information - Teacher

44. Which of the following best describes your move from last year's position to your current position?
In the same state

In a different state

Moved from one public school to another public school in
the SAME SCHOOL DISTRICT
Moved from one public school district to ANOTHER
PUBLIC SCHOOL DISTRICT
Moved from a PUBLIC school to a PRIVATE school
Moved from a PRIVATE school to a PUBLIC school
Moved from one PRIVATE school to another PRIVATE
school
Other

45. Indicate the level of importance EACH of the following played in your decision to leave LAST YEAR'S SCHOOL.
Not at all
important

Slightly important

Somewhat
important

Very important

Extremely
important

Salary and benefits are better in
my current position.
I felt job security would be better
in my current position.
I was dissatisfied with workplace
conditions (e.g., facilities,
classroom resources, school
safety) in my previous position.
I was dissatisfied with my last
position for reasons not stated
above.

Education and Demographic Information

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46. Check the degree(s) or certificate(s) or endorsement(s) you held when you 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

47.

Check the degree(s) or certificate(s) or endorsement(s) you 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 license/certificate/credential
State-issued Endorsement
Other, please specify

48.

What is your gender?
Female

49.

Male

Which of the following best describes you? Please select one or more.
American Indian or Alaskan Native
Asian

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Black or African American
Native Hawaiian or Other Pacific Islander
White
Other, please specify

50. Are you Hispanic or Latino?
Yes

No

Note: When a scholar reaches the end of the survey, or answers a question that automatically ends the survey, they will receive a
confirmation message and will be notified that they will be contacted within one year with a request to update their information. Once the
survey is ended, it is automatically uploaded into the Scholar Tracking System.

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