IHE Questionnaire

OMB Control Number: 1820-0686

E xpiration: XX/XX/XXXX

Service Obligation Tracking System Scholar/Obligee Record Form

OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

OMB Paperwork Reduction Statement

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. Public reporting burden for this collection of information is estimated to average 7 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is mandatory per the Individuals with Disabilities Education Act of 2004 (IDEA) and its corresponding requirements, 34 CFR Part 304 Volume 70 No. 57 March 25, 2005, and regulations, 34 CFR Part 304 Vol. 71 No. 107 June 5, 2006, printed in the Federal Register. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email [email protected] and reference the OMB Control Number 1820-0686. Note: Please do not return the completed Scholar/Obligee Record Form to this address.

Rules of Behavior for Department of Education-Sponsored Website

The NCSO Service Obligation Tracking System (SOTS) is an online data collection system designed to facilitate administration of the U.S. Department of Education Office of Special Education Programs' (OSEP's) Personnel Development Program. This system collects employment and contact information from participating scholar/obligees to verify the fulfillment of their service obligation. Verifying service obligation requires collecting personally identifying information from Institutions of Higher Education, scholars/obligees, and employers. This data collection has been authorized by the Individuals with Disabilities Education Act of 2004 (IDEA) and its corresponding requirements 34 CFR Part 304 printed in the Federal Register Volume 70 No. 57 March 25, 2005 and regulations Vol. 71 No. 107 June 5, 2006

Users of the SOTS must agree to certain conditions and agree to act to insure the accuracy and confidentiality of the information stored by the SOTS.

Employers using this system agree to:

* Maintain the confidentiality of requested employment information about scholars/obligees.

* Maintain confidentiality of system login and password.

* Verify scholar/obligee employment within 30 days of the annual notification e-mail from NCSO.

□ I agree to the terms.

Scholar/Obligee Record

Please complete the following questions for the scholar/obligee record. Required items are marked with an asterisk. You will be logged out of the system after 30 minutes of inactivity. A warning message will appear after 25 minutes of inactivity.

Please note that scholars/obligees may only be entered into the SOTS under one grant. If a scholar/obligee is funded under multiple OSEP funded grants please contact the NCSO Helpdesk to report the information.

In addition, please note that at this time, the SOTS only collects domestic contact address information. If you need to report an international contact address for a scholar/obligee please contact the NCSO Helpdesk to report the information.

You must ensure that all information is accurate and complete before submitting a record. Once a record is submitted for a scholar/obligee who has exited or completed a program, it CANNOT be edited. Once a record is submitted for an exited or completed scholar/obligee, the scholar/obligee is given access to the database for input of employment information. To edit submitted records for exited or completed scholars/obligees, please contact the NCSO Helpdesk.

Individuals who receive scholarship assistance from projects funded under IDEA are required to complete a service obligation or repay all or part of the costs of such assistance. For each academic year scholars receive assistance they must maintain full-time employment for the equivalent of two years, or repay the Federal government for the portion of assistance they received that has not been repaid through service. FY 2005 Requirements: Sec. F; 2006 Regulations: §304.30.

Exited scholars/obligees who have completed their program or at least one academic year of training may fulfill the obligation through service. Scholars/obligees who exit a program prior to its completion and have not finished at least one academic year of training will be referred for repayment to the Accounts Receivable Group of the U.S. Department of Education. FY 2005 Requirements: Sec. F (j)(4)(iii); 2006 Regulations: §304.30.(j)(4)(iii).

Currently enrolled scholars/obligees are given access to the system when their records are submitted if they have completed one or more academic years of training, making them eligible to begin fulfilling their service obligation. FY 2005 Requirements: Sec. F (f)(2); 2006 Regulations: §304.30(f)(2). Records submitted for currently enrolled scholars/obligees can be edited.

Pending records are those that are saved for later: they can be edited. To save a record for later, you must the check the box in Section G indicating that all available information has been entered.

Grant Award Number: ______________

A. Identifying Information
*First Name			Middle Name		*Last Name
Maiden Name, if applicable:
*Social Security Number			--	--
*Primary E-mail Address
*Verify Primary E-mail Address
Alternative E-mail Address
Verify Alternative E-mail Address
* Required fields necessary to submit a record.

B. Contact Information
Primary Address
*Address
*City		*State		*Zip Code
*Phone		Fax
	(XXX) XXX-XXXX		(XXX) XXX-XXXX
Secondary Address
Address
City		State		Zip Code
Phone		Fax
	(XXX) XXX-XXXX		(XXX) XXX-XXXX
* Required fields necessary to submit a record.

B. Contact Information
International Primary Address
*Name of Addressee
*City or Town				*Country Name			*Postal Code
*Phone				Fax
Secondary Address
Name of Addressee
City or Town				Postal Code
Phone				Fax
* Required fields necessary to submit a record.

C. Education and Demographic Information

1.* 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’s Degree
 □  Bachelor's Degree
 □  Master's Degree
 □  Educational Specialist
 □  Doctoral Degree
 □  Postdoctoral Degree
 □  State or Professional Credential/Certificate
 □ State-issued Endorsement
 □  Grantee-issued Endorsement
 □  Other (please specify) __________

 □  This information is not available

2.* 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):
 □  Associate’s Degree
 □  Bachelor's Degree
 □  Master's Degree
 □  Educational Specialist
 □  Doctoral Degree
 □  Postdoctoral Degree
 □  State or Professional Credential/Certificate
 □ State-issued Endorsement
 □  Grantee-issued Endorsement
 □  Other (please specify) __________

 □  The scholar/obligee is currently enrolled in the training program
 □  The scholar/obligee has exited the training program without completion

3.* What is the scholar’s/obligee's gender?  ○ Female  ○ Male

4. Which of the following best describes the scholar/obligee? 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)__________

5. Is the scholar/obligee Hispanic or Latino?  ○ Yes  ○ No

* Required fields necessary to submit a record.

D. Secondary Contact Information
Address and contact information for a relative or other person through which NCSO may contact the scholar/obligee, if necessary.
First Name				Last Name
Address
City			State		Zip Code
Phone			Fax
	(XXX) XXX-XXXX			(XXX) XXX-XXXX
Secondary Phone:
	(XXX) XXX-XXXX
E-mail Address
Verify E-mail Address
* Required fields necessary to submit a record.

D. International Secondary Contact Information
Address and contact information for a relative or other person through which NCSO may contact the scholar/obligee, if necessary.
First Name				Last Name
Name of Address
City or Town			Country Name		Postal Code
Phone			Fax
Secondary Phone:
E-mail Address
Verify E-mail Address
* Required fields necessary to submit a record.

E. Program Information

1.* Select one special education and/or related services training area that best describes the training focus of the degree(s) or certificate(s) or endorsements(s) that this scholar/obligee received from this grant-supported training.

I. Special Education

II. Related Services

□	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
□	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

□	Audiology
□	Counseling
□	Educational diagnostician
□	Interpreter/ASL
□	Music therapy
□	Nursing
□	Occupational Therapy
□	Orientation & mobility
□	Paraprofessional
□	Physical therapy
□	Rehabilitation counseling
□	School counseling
□	Psychology
□	Speech/language
□	Social work
□	Therapeutic recreation
□	Work experience coordinator (employment transition specialist)

If the special education and related services areas above are not appropriate for the training focus of your grant, please provide a brief description of the training focus of the student’s degree(s) or certificate(s) or endorsement(s) below.

__________________________________________________________________________

2. If appropriate, select up to three additional training areas to provide more detailed information about the scholar/obligee’s focus of training.

I. Special Education

II. Related Services

□	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
□	Deaf-blindness
□	Mental retardation: Mild/moderate
□	Mental retardation: Severe
□	Other health impairment
□	Physical impairment/orthopedic impairment
□	A
□ apted physical education	Assistive technology
□	Bilingual special education/ESL/TESOL
□	Early childhood/early intervention
□	Inclusive/collaborative practices
□	Special education for youth in correctional facilities
□	Transition

* Required fields necessary to submit a record.

□	Audiology
□	Counseling
□	Educational diagnostician
□	Interpreter/ASL
□	Music therapy
□	Nursing
□	Occupational therapy
□	Orientation & mobility
□	Paraprofessional
□	Physical therapy
□	Rehabilitation counseling
□	School counseling
□	Psychology
□	Speech/language
□	Social work
□	Therapeutic recreation
□	Work experience coordinator (employment transition specialist)

 F. Training Program Exit/Completion Status

Please indicate the appropriate program status of the scholar/obligee below. You must complete all subquestions for the option selected.

* Scholar/obligee program exit or graduation/completion status:
Select the most appropriate option below.

○ The scholar/obligee is still enrolled and is currently receiving funding

○ The scholar/obligee is still enrolled in the program but is no longer receiving OSEP funding because:

○ The grant ended

Please enter the date of exit/graduation/completion, if applicable.

__________ (mm/dd/yyyy)

Is it expected that the student will be enrolled in this grant-supported training at a future date?
○ Yes

○  No

○  Don’t know

Please enter the date the grant ended:__________ (mm/dd/yyyy)
(The date above reflects the most recent end date in the grant profile. If you edit the grant end date, you will be prompted to update the grant profile.)

○ Other

Please specify other reason scholar/obligee is no longer receiving OSEP funding.

___________________________________________________________

Is it expected that the student will be enrolled in this grant-supported training at a future date?
○ Yes

○  No

○  Don’t know

○ The scholar/obligee graduated/completed the program

Please enter the date of exit/graduation/completion, if applicable.

__________ (mm/dd/yyyy)

○ The scholar/obligee exited without graduating/completing the program

Please enter the date of exit without completion:__________ (mm/dd/yyyy)

What are the reason(s) that the scholar/obligee is no longer enrolled in this grant-supported training? (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
□	Obtained employment
□	Other personal reasons
□	Poor academic performance
□	Poor practicum/field-based performance
□	Grant support terminated due to grant ending

Please enter the date the grant ended: __________ (mm/dd/yyyy)

(The date above reflects the most recent end date in the grant profile. If you edit the grant end date, you will be prompted to update the grant profile.)

Is it expected that the student will be enrolled in this grant-supported training at a future date?
○ Yes
○ No
○ Don’t know

* Required fields necessary to submit a record.

G. Obligation Information

Below you must enter the service obligation details for the scholar/obligee. This information is critical to tracking service obligation fulfillment.

Note that after the completion of at least one academic year of training a scholar/obligee may begin to fulfill his or her service obligation. FY 2005 Requirements: Sec. F (f)(2); 2006 Regulations: §304.30(f)(2). An academic year is defined by the program regulations as "(1) A full-time course of study- (i) Taken for a period totaling at least nine months; or (ii) Taken for the equivalent of at least two semesters, two trimesters, or three quarters; or (2) For a part-time scholar, the accumulation of periods of part-time courses of study that is equivalent to an ‘academic year’ under paragraph (a) (1) of this definition." FY 2005 Requirements: Sec. B (1)- (2); 2006 Regulations: §304.3(a)(1)-(2).

Scholars/obligees who exit a training program prior to its completion have not finished at least one academic year of training will be referred for repayment to the Accounts Receivable Group of the U.S. Department of Education. Scholars/Obligees will not receive credit for any employment positions held prior to the date of completion of one academic year. If a training program is less than one academic year in duration, scholars/obligees will not receive credit for any employment positions held prior to the date of completion. FY 2005 Requirements: Sec. F (j)(4)(iii); 2006 Regulations: §304.30.(j)(4)(iii).

1.* Program Duration:
  Select the most appropriate option below.
○   This program is less than one academic year in duration.

○   This program is more than one academic year in duration, but the scholar/obligee has not yet completed one academic year of training.

○   This program is more than one academic year in duration and the scholar/obligee completed one academic year of training on __________ (mm/dd/yyyy).

2.* Accumulated academic years of funding (to date, if enrolled):__________

Enter durations less than one academic year as decimals. For example, 0.5 is half of one academic year of funding.

3.* Total service obligation in months (to date, if enrolled):__________

This amount is calculated by multiplying accumulated academic years of funding by 24 months. Two years of service obligation are required for every academic year of scholarship support.

4.* Total funding amount to date if enrolled (to date if enrolled): __________

Enter the amount of funding in dollars and cents.

* Required fields necessary to submit a record.

H. Information Verification

You must check the box below to submit the record or save the record for later.

 □   Yes, all information available for this scholar/obligee has been entered.

SOTS Scholar/Obligee Status Definitions

(View All Scholar/Obligee Records Page on SOTS)

Below are the definitions for the record entry status, program completion status, and service obligation status for scholars/obligees. To add new scholars/obligees, click on the “Add New Scholar” link. To access a list of all scholars/obligees, select a grant number below and click "Retrieve Records". Once you have accessed the list of scholars/obligees, click the “View/Print Status Report” link to generate a PDF report of the list for printing or saving.

Record Entry Status

1. Pending: A record that has been saved for later. Because these records have not been submitted to NCSO for processing, they can be edited.

2. Submitted:

* Clicking on the “Save and Submit” button at the end of the scholar/obligee record will release the record to NCSO for processing. A scholar/obligee will be prompted by the database to enter eligible employment information if he or she is currently enrolled but finished at least one academic year training, exited prior to completion but finished at least one academic year training, or completed a program.

* Records submitted for currently enrolled scholars/obligees can be edited.

* Records submitted for scholars/obligees who exited prior to completion or completed a program CANNOT be edited. To edit submitted records for these scholars/obligees, please contact the NCSO Helpdesk.

* All required fields must be entered for a record to be submitted. Required fields are marked by an asterisk on the scholar/obligee profile. The following are required information fields:

• First name

• Last name

• Gender

• Social Security Number

• Primary e-mail

• Primary address

• Phone number

• Degrees prior to training program

• Degrees after training program

• Program training areas

• Program exit/completion status

• Date of exit/completion

• Reason for exit if prior to completion

• Date of one academic year completion

• Accumulated academic years of funding

• Length of service obligation in months

• Amount of service obligation in dollars

Scholar/Obligee Program Completion Status

1. Enrolled: The scholar /obligee is currently enrolled in the funded training program but may or may not be receiving grant funding. After completing one academic year of training, these scholars/obligees may begin working in eligible employment. Therefore, currently enrolled scholars/obligees may have a Service Obligation Status of Fulfillment in Progress or Fulfillment Not in Progress.

2. Completed/Graduated: The scholar/obligee has completed the funded training program and may begin fulfilling his or her service obligation.

3. Exited Without Completion: The scholar/obligee has exited the OSEP training program without completing the program. If the scholar/obligee has completed at least one academic year of training, he or she may fulfill the service obligation through eligible employment. If the scholar/obligee has not finished at least one academic year of training, he or she will be referred to the Accounts Receivable Group of the U.S. Department of Education for monetary repayment of the scholarship funds.

Scholar/Obligee Service Obligation Status

1. Awaiting Login: The scholar/obligee has never logged into the SOTS.

2. Awaiting Completion: The scholars/obligee is currently enrolled in a training program, but has not completed one academic year of training and therefore, cannot begin to fulfill his or her service obligation through eligible employment. These scholars/obligees do not have access to the Service Obligation Tracking System (SOTS).

3. Fulfillment in Progress: The scholar/obligee has logged into the SOTS and has entered eligible employment records.

4. Fulfillment Not in Progress: The scholar/obligee has logged into the SOTS, but has not entered eligible employment records. Scholars/obligees within grace period are not required to be in eligible employment.

5. In Repayment: The scholar/obligee is out of compliance with program regulations or has opted to repay the scholarship funds, and has been referred to the Accounts Receivables Group of the U.S. Department of Education for monetary repayment of scholarship funds.

6. In Deferral: The scholar/obligee has an approved deferral of service obligation fulfillment or repayment during which he or she cannot work in eligible employment. Employment records with start and end dates during the deferral period will not accepted in the SOTS. See Frequently Asked Questions at www.serviceobligations.ed.gov/FAQ.cfm for a listing of approved reasons for deferrals.

7. In Exception: The scholar's/obligee's debt has been canceled due to death or permanent disability.

8. Obligation Fulfilled: The scholar/obligee has completed the total service obligation owed or repaid the full funding amount.

PO Box 2335, Hyattsville, MD 20784-2324

E-mail: [email protected] | Web site: http://serviceobligations.ed.gov | Phone: 800-285-NCSO (6276)