Scholar Training & Employment

OMB Control Number: 1820-0686

E xpiration: XX/XX/XXXX

Service Obligation Tracking System Scholar/Obligee Employment 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 18 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 Employment Record Form application 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.

Employment Record Form

Employment Information

The questions relating to your employment affect your obligation fulfillment status. You must answer every question to the best of your ability. Providing information that you know to be false may be punishable by law.

1. 1. Does your current or previous employment fulfill your service obligation?

• Yes

• No

Employment Information

2. 2. Is this position a substitute teaching position?

• Yes

• No

Employer Information

You must provide the name, address, and phone number of the employer organization for this position. If your employment position is outside of the United States, please contact the NCSO Helpdesk to report your employment information. You must list at least one supervisor or human resources manager who can verify your employment and provide his or her e-mail address. You will be asked on the next page to indicate which contact should be sent your employment record for verification. Lastly, you must indicate the type of employer organization for this employment position.

*Organization Name: ______________________________

Department Name: ________________________________

Organization Address

*Address Line 1: Address Line 2:

___________________________ __________________________

*City: *State: *Zip Code:

________________ ___________ ______-____

*Phone: Fax:

_________________ (xxx-xxx-xxxx) ___________________ (xxx-xxx-xxxx)

TTY:

_____________________ (xxx-xxx-xxxx)

Organization Web site address: (Ensure the Web site has the prefix "http://".):

__________________________________

Supervisor

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

*First: *Last:

___________________________ __________________________

Supervisor’s Business Address

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ (xxx-xxx-xxxx) ___________________ (xxx-xxx-xxxx)

*E-mail: *Verify E-mail:

_________________ ________________

Alternative E-mail Address: Verify Alt. E-mail:

_________________ ___________________

Fax: TTY:

_____________________ (xxx-xxx-xxxx) _____________________ (xxx-xxx-xxxx)

Human Resource Manager

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

*First: *Last:

___________________________ __________________________

Human Resource Business Manager’s Address: 

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ (xxx-xxx-xxxx) ___________________ (xxx-xxx-xxxx)

*E-mail: *Verify E-mail:

_________________ ________________

Alternative E-mail Address: Verify Alt. E-mail:

_________________ ___________________

Fax: TTY:

_____________________ (xxx-xxx-xxxx) _____________________ (xxx-xxx-xxxx)

International Employer Information

You must provide the name, address, and phone number of the employer organization for this position. You must list at least one supervisor or human resources manager who can verify your employment and provide his or her e-mail address. You will be asked on the next page to indicate which contact should be sent your employment record for verification. Lastly, you must indicate the type of employer organization for this employment position.

*Organization Name: ______________________________

Department Name: ________________________________

Organization Address

*Name of Addressee

___________________________

*City or Town: *Country Name: *Postal Code:

________________ ___________ ______-____

*Phone: Fax:

_________________ ___________________

TTY:

_____________________

Organization Web site address: (Ensure the Web site has the prefix "http://".):

__________________________________

Supervisor

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

*First: *Last:

___________________________ __________________________

Supervisor’s Business Address

Name of Addressee:

___________________________

City or Town: Country Name: Postal Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ ___________________

*E-mail: *Verify E-mail:

_________________ ________________

Alternative E-mail Address: Verify Alt. E-mail:

_________________ ___________________

Fax: TTY:

_____________________ _____________________

Human Resource Manager

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

*First: *Last:

___________________________ __________________________

Human Resource Business Manager’s Address: 

Name of Addressee:

___________________________

City or Town: Country Name: Postal Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ ___________________

*E-mail: *Verify E-mail:

_________________ ________________

Alternative E-mail Address: Verify Alt. E-mail:

_________________ ___________________

Fax: TTY:

_____________________ _____________________

Organization Type
1. What type of organization is this?* Public School Residential School For-profit or Commercial Organization Federal Government Agency State or Local Government Agency	Private School Hospital College/University Non-Profit Organization Other, Please Specify:

Employment Information

Please note that past employment records cannot be edited once submitted for verification. Your employer will have 30 days from the date of submission to verify or dispute your employment information for this position. Current employment records can be edited. You will receive credit for current employment up to the date of last update. You cannot update your current employment record during your employer’s 30–day verification period until your employer verifies or disputes the record or the 30-day verification window expires. Also note that per 2005 Requirements Sec.F(f)(2) and 2006 Regulations §304.30(f)(2), you will not receive credit for work completed prior to date you completed of one academic year of training.

Classroom teachers with 12 month contracts must indicate 12 months of employment to receive a year of service obligation credit. If you enter the start and end dates of the school year you will only receive credit for the number of months entered.

Question #7 does not affect your service obligation fulfillment status. This question is for measuring performance of the programs at the Office of Special Education Programs.

To save a record for later completion, please click the "Save For Later" button at the bottom of the page.

1. *Is this your current employment?

• Yes

• No

*When did this job begin? (mm/dd/yyyy) When did this job end? (mm/dd/yyyy)

Please note: past employment records cannot be edited once submitted.

2. *Which of the following best describes the position?*

• Classroom Teacher

• Paraprofessional/Teacher Assistant/Teacher Aide

• Teaching at the Postsecondary Level

• Policy

• Program Development

• Instructional Specialist

• Supervision (including the capacity of a principal)

• Research

• Technical Assistance

• Administration

• Other, Please Specify:

3. *Is this a full or part-time position?

• Full Time (As defined by your Employer)

• This is a summer position

• This position has summers off

• This is a year round position

• Part Time

3a. If this employment is part-time, on average, how many hours does the scholar work per week at this job? ______

4. Select one special education and/or related services training area that best describes this employment position.

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)

I f the special education and related services areas above are not appropriate for the training focus of your employment, please provide a brief description of the area of focus for this employment.

5. If appropriate, select up to three additional training areas to provide more detailed information about this employment position.

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)

Please answer the questions below that best describe the work you do in this position. Eligible employment must 1) fulfill at least one of the requirements listed in Sec. F (e) of the 2005 Requirements or §304.30(e) of the 2006 Program Regulations; 2) provide compensation; and 3) if serving children, the children must fall under the definition of eligible children as described in IDEA 2004 Sec. 602(3).

6. *Describe the percentage of time spent performing work related to the training for which the scholarship was received under Section 662 of IDEA the Individuals with Disabilities Education Act of 2004 in this position.

• Less than 40%

• 40% -- 50%

• 51% -- 60%

• 61% or greater

• N OT APPLICABLE

N ote:

Please complete Questions 6a. and 6b. only if you selected one of the following answers for Question 2: Which of the following best describes the position?:

Classroom Teacher

Paraprofessional/Teacher Assistant/Teacher Aide

Instructional Specialist

6a. Describe the percentage of time spent teaching or serving special education students in this position.

• Less than 40%

• 40% -- 50%

• 51% -- 60%

• 61% or greater

• NOT APPLICABLE

6b. Describe the percentage of special education students taught or served in this position.

• Less than 40%

• 40% -- 50%

• 51% -- 60%

• 61% or greater

• NOT APPLICABLE

6.  *Are you "highly qualified/qualified/fully certified" for this position under Individuals with Disabilities Education Act (IDEA) and/or the Elementary and Secondary Education Act (ESEA)? Select the most appropriate answer.
   "Highly qualified/qualified/fully certified" for purposes of this data collection means that the employee meets the state requirements (if there are requirements in your state) for certification/licensure for this position.

• {Highly qualified/qualified/fully certified}

• {Not highly qualified/Not qualified/Not fully certified}

• This state does not have requirements for certification/licensure for this position

• Not applicable to this type of employment position

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." 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.”

Please provide the name and the e-mail of the employer contact(s) you would like to receive the verification request:

Note: Please complete the following section, Position Change Information, only if you selected “No” for Question 1: Is this your current employment? and elected one of the following answers for Question 2: Which of the following best describes the position?:

Classroom Teacher

Paraprofessional/Teacher Assistant/Teacher Aide

Instructional Specialist

Position Change Information

Which of the following best describes your move from THIS position to your NEXT position? You may choose only one. 

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 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 a PRIVATE school to another PRIVATE school.

Other, please specify:

 ________________________________

Indicate the level of importance EACH of the following played in your decision to THIS position.

	Not at all important	Slightly important	Somewhat important	Very important	Extremely important
Salary and benefits are better in my current or most recent position.
I felt job security would be better in my current or most recent 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.

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PO Box 2335, Hyattsville, MD 20784-2324

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