Employer Verification

Paperwork Burden Statement
Employer Verification
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 938 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 –
Employer Verification
Employee Identification Verification
1. Employee name
First Name
Middle Name
Maiden Name, if
applicable
Last Name

2. Employee Social Security number

3. Employee date of birth
mm-dd-yyyy

Employer Information
4. Name of employee's supervisor
First Name
Last Name

5. Supervisor's address
Address Line 1
Address Line 2
City
State
Zip Code

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Phone
Mobile Phone
Fax
TTY
E-mail Address
Verify E-mail Address
Alternative E-mail
Address

6. Name of human resources manager
First Name
Last Name

7. Human resources manager address

Please enter the information below if it differs from the information provided above.

Address Line 1
Address Line 2
City
State
Zip Code
Phone
Mobile Phone
Fax
TTY
E-mail Address
Alternative E-mail
Address

8. Name of person completing this form

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Employee Position Information
Questions marked in red do not affect employee obligation fulfillment status.
These questions are for measuring performance of the programs at the Office of Special
Education Programs.
9. Is the employee {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 the employee
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, the employee
can be “highly qualified”; if the position is general education/special education paraprofessional/aide or early
intervention, early childhood or preschool paraprofessional/aide, the employee 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, the employee can be “fully certified.”
For more information on the definition of Highly Qualified please click here.

10. When did this job begin?
mm-dd-yyyy

11. When did this job end?

Leave blank if the employee is currently employed in this job.
mm-dd-yyyy

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

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14. Which one of the following best describes the position held by employee?
Classroom Teacher
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

15. Does this position serve students in these Special Education Service Areas?
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
Emotional disturbance/behavioral disorders
Autism
Traumatic brain injury
Deafness and/or hard-of-hearing
Visual impairment and/or blindness

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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
Transition
Other, please specify

16. 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

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School counseling
Psychology
Speech/language
Social work
Therapeutic recreation
Work experience coordinator (employment transition specialist)
Other, please specify

Employment Information
17. Describe the percentage of time this employee taught or served special education students for the
current or most recent school year.
Less than 40%
40% -- 50%
51% -- 60%
61% or greater

18. Describe the percentage of special education students this employee taught or served on this job for the
current or most recent school year.
Less than 40%
40% -- 50%
51% -- 60%
61% or greater

19. 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%

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61% or greater

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