Employer Verification

OMB Control Number: 1820-0686

E xpiration: XX/XX/XXXX

Service Obligation Tracking System Employment Verification 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 17 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 voluntary. 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 Verification 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.

Employment Verification Page 1

Welcome to the Service Obligation Tracking System (SOTS) of the National Center on Service Obligations (NCSO). The obligee listed below accepted a scholarship from a grant awarded to an Institution of Higher Education (IHE) by the Department of Education's Office of Special Education Programs Personnel Development Program (PDP). These scholarships include a service obligation requirement of 2 years of eligible employment for each year of IHE support. Obligees are required to provide NCSO with annual updates about their employment in order for NCSO to track the fulfillment of their service obligation. Additional information about NCSO and the service obligation is available on the NCSO Web site at http://www.serviceobligation.ed.gov.

Please take a moment to verify the accuracy or to correct any inaccuracies of the information provided by the obligee. We anticipate that the survey will take no longer than 10 minutes to complete. Your session will timeout after 30 minutes of inactivity and the information entered will not be saved.

Do NOT use your internet browser's back button during this process. Thank you for taking the time to provide this information!

Employee Name: 

* Required fields necessary to submit a record.

Employer Information

*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 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

*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

*Organization Name: ______________________________

Department Name: ________________________________

Organization Address

*Name of Addressee

___________________________

*City or Town: *Country Name: *Postal 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

Name of Addressee:

___________________________

City or Town: Country Name: Postal 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: 

Name of Addressee:

___________________________

City or Town: Country Name: Postal 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)

Employment Verification Page 2 Please review the information below.

If you AGREE with all of the obligee’s responses, click the Proceed button at the bottom of the page. If you DISAGREE with the obligee's response to a particular question, please check the box beside the question. Once you have selected all the questions for which you disagree with the response, click the “Proceed” button at the bottom of the page. You will have an opportunity to describe the reason for your disagreement on the following page. An Employment Verification Report will be sent to the obligee and he or she will have the opportunity to accept your changes or revise and resubmit for verification. .

Employee Name: 

Employee Position Information

Questions marked in blue do not affect the obligee's service obligation fulfillment status. These questions are for measuring performance of the programs at the Office of Special Education Programs.

1. * When did this job begin? (mm/dd/yyyy) Disagree □

Obligee Answer:

2. *Is the obligee currently employed in this position? Disagree □

Obligee Answer:

3. * Is this full time or part time employment? Disagree □

Obligee Answer:

4. *Which of the following best describes the position?* Disagree □
   
   Obligee Answer:
   
   

• 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:
  
  

5. Describe the percentage of time spent teaching or serving special education students in this position.
   
   Disagree □
   Obligee Answer:
   
   

• Less than 40%

• 40% -- 50%

• 51% -- 60%

• 61% or greater

• Not Applicable

6. Describe the percentage of special education students taught or served in this position.
   
   Disagree □
   Obligee Answer:
   
   

• Less than 40%

• 40% -- 50%

• 51% -- 60%

• 61% or greater

• Not Applicable

7.  * Is the obligee "highly qualified/qualified/fully certified" for this position under Individuals with Disabilities Education Act (IDEA) and/or the Elementary and Secondary Education Act (ESEA)? "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.

Obligee Answer:

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".

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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)