Participant Record Form

OMB Control Number: 1810-0698

Expiration: 4/30/201

Indian Education Professional Development

Data Collection System

Grantee Reporting Form

OMB Control Number: 1810-0698

Expiration: 4/30/2016

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 44 hours per participant, 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 section 7122 of the Elementary and Secondary Education Act of 1965, as amended, and its corresponding regulations, 34 CFR Part 263, Subpart A. 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 1810-0698. Note: Please do not return the completed Participant Record Form to this address.

Rules of Behavior for Department of Education-Sponsored Website

The Indian Education Professional Development (IEPD) Data Collection System (DCS) is an online data collection system designed to facilitate administration of the IEPD Program. This system collects employment and contact information from participants to verify the fulfillment of their payback agreements. Verifying payback requires collecting personally identifying information from grantees, participants, and employers. This data collection has been authorized by section 7122 of the Elementary and Secondary Education Act of 1965, as amended, and its corresponding regulations, 34 CFR Part 263, Subpart A.

Users of the DCS must agree to certain conditions and agree to act to insure the accuracy and confidentiality of the information stored by the DCS. Violation of this policy will result in suspension of grantee access to the DCS.

Users representing grantees agree to:

• Maintain requested grant information, including grant contact information, and

• Maintain DCS accounts established to collect grant, grantee and participant information by:

• Protecting account login names and passwords;

• Submitting participant information as requested by DCS;

• Reviewing participant information for accuracy; and

• Protecting the confidentiality of personally identifying information requested by DCS.

By agreeing to these Rules of Behavior, grantee representatives agree to maintain the confidentiality of this information.

□ I agree to the terms.

Grantee Reporting Form Instructions

Please complete the following questions for each participant in your grant-supported training program.

You will only need to enter information for Sections A through F once for each participant. In subsequent months, you will just need to make changes whenever the reported information has changed. Required items are marked with an asterisk.

You must enter information for Section G each time a participant has a change in status.

All changes in participant status (e.g., recruitment, leave of absence, military deployment, training completion, exiting without completion) must be entered in the DCS within 7 business days of the change in status or by the end of the month in which the change occurred.

You must enter the cumulative total number of months the participant has been enrolled in the training program along with the cumulative total allowable training costs at the end of each semester in Section H. Final totals must be entered when the participant leaves the program. This information will be visible to the participant so he/she can see their payback obligation amounts as they are incurred.

You will only need to enter information for Section I when the participant exits your program.

Data Entry Information

You will be logged out of the system after 30 minutes of inactivity. A warning message will appear after 25 minutes of inactivity.

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 J indicating that all available information has been entered.

You must ensure that all information is accurate and complete before submitting a record. Once a record is submitted for a participant who has exited or completed a program, it CANNOT be edited. To edit submitted records for exited or completed participants, please contact the Data Collection Center (DCC) Helpdesk at 1-888-884-7110 or [email protected].

Grant Award Number: [PRE-FILLED]

* Required fields necessary to submit a record.

A. Identifying Information
*First Name			Middle Name		*Last Name
Maiden Name, if applicable:
*Social Security Number			--	--
*Date of Birth
*Primary E-mail Address
*Verify Primary E-mail Address
Alternative E-mail Address
Verify Alternative E-mail Address

B. Contact Information
Primary Address
*Address
*City		*State		*Zip Code
*Home Phone		Cell Phone
Secondary Address
Address
City		State		Zip Code
Other Phone		Fax

C. Alternate Contact Information

Address and contact information for a relative or other person through which DCC may contact the participant, if necessary.

First Name

Last Name

E-mail Address

Verify Primary E-mail Address

Address

City

State

Zip Code

Home Phone

Other Phone

Fax _____

D. Service Payback Agreement

A. Please download the Service Payback Agreement

[INSERT LINK TO FILE FOR DOWNLOAD].

Complete form and obtain signatures. All participants must sign a Service Payback Agreement prior to receiving grant funds.

B. Please upload a copy of the completed and signed Service Payback Agreement.

File to upload:_______

Download previously uploaded Service Payback Agreement [link to agreement, if uploaded]

You may upload an electronic copy of the signed service payback agreement or you may mail or fax the document to the DCC Help Desk at 1600 Research Blvd., RB 2268, Rockville, MD, 20850 or 888-252-6960.

Depending on the file size of the attachment, the upload process may take up to several minutes. Acceptable file types include .doc, .docx., and .pdf. Please note that file names or titles cannot have spaces. You may use underscores (e.g., John_Doe_service_payback_agreement.doc).

E. Training Prior to Entry into Project Training

*1. Check the degree(s) or certificate(s) or endorsement(s) the participant held when he/she entered this grant-supported training (check all that apply):
 □  High school diploma or equivalency [If only degree, go to Section F]
 □  Associate’s Degree
 □  Bachelor's Degree
 □  Master's Degree
 □  Educational Specialist
 □  Doctoral Degree
 □  Postdoctoral Degree
 □  State, Tribal or Professional Credential/Certificate
 □ State-Issued Endorsement
 □  Grantee-Issued Endorsement

*2. If the participant was granted a degree/certificate/endorsement prior to entry into this grant-supported training, the area(s) was (check all that apply):

 □  Related to education
 □  Outside the field of education [If only response selected, go to Section F]

*3. If the participant was granted a degree/certificate/endorsement within the field of education prior to entry into this grant-supported training, select the specific area(s) of education: (check all that apply):

General Education

 □  Administration
 □  Elementary Education

 □  Secondary Education

 □  Social Work
 □  School or Educational Psychology

 □  Special Education

Subject Area

□  Arts and Music

 □  Bilingual or English as a Second Language

 □  Early Childhood Education

 □  English or Language Arts

 □  Language Education (Native/Heritage/World Language)

 □  Health or Physical Education

 □  Mathematics or Computer Science

 □  Natural Sciences

 □  Social Sciences

 □  Career or Technical Education

 □  Other (please specify) __________

F. Project Training Information

*1. Date Participant Started Project Training: __________ (mm/dd/yyyy)

*2. Type of position project is training participant to become: (check one):

2. ○  Paraprofessional/Teacher Assistant/Teacher Aide

3. ○  Teacher
   ○  Administrator

4. ○  Teacher and Administrator

○  Social Work

○  Ancillary Educational Personnel

○  Other (please specify) __________

*3. Is the participant a:

 ○  Full-time student (i.e., carries a full course load as defined by your institution, and is not employed more than 20 hours/week)

○  Full-time student (i.e., carries a full course load as defined by your institution, and is employed 20+ hours/week)

 ○  Part-time student (i.e., anything less than full-time)

 G. Participant Status

Please indicate the appropriate program status of the participant below.

*1. Select the most appropriate option below.

○ The participant is still enrolled in project training. [Go to Section G, Item 2]

○ The participant is taking a leave of absence. [Go to Section G, Item 2]

○ The participant is on active military deployment. [Go to Section G, Item 2]

○ The participant has completed project training. [Go to Section H,]

○ The participant has exited project training prior to completion. [Go to Section H I1 and 12, skip 13 to 15 ]

*2. Date Participant Expected to Complete Project Training: __________ (mm/dd/yyyy) [Go to Section H]

H. Service Payback Information

Below you must enter the service payback details for the participant. This information is critical to tracking service payback fulfillment. Please report cumulative totals.

*1. Total number of months participant was enrolled in training as of <PREFILL CURRENT DATE>(Round to the nearest whole month):__________

*2. Total allowable training costs as of <PREFILL CURRENT DATE>:

Type of Expense	Cost (round to nearest whole dollar)
Tuition, Books, and Fees	$
Stipend (i.e., costs related to room, personal living expenses, and/or board)	$
Dependent Allowance	$
Supplies (non-technology)	$
Technology (i.e., computers, and related items)	$
Required Program Travel	$
Miscellaneous (explain)	$
TOTAL	$[Sum of above]

□ Check this box if the cumulative totals above represent the final amounts for this participant. This box should only be checked if the participant has completed the program or exited the program prior to completion.

[After completing section H if response to item 1 in section G was one of the first three options then skip section I]

I. Participant Exit Information

*1. Please enter the date of exit/graduation/completion: __________ (mm/dd/yyyy)

*2. Select the primary subject area emphasized in training (check all that apply):

General Education

Administration

Elementary Education

Secondary Education

Social Work

School of Educational Psychology

Special Education

Subject Area

○ Arts and Music

○ Bilingual or English as a Second Language

○ Early Childhood Education

○ English or Language Arts

○ Language Education (Native/Heritage/World Languages)

○ Health or Physical Education

○ Mathematics or Computer Science

○ Natural Sciences

○ Social Sciences

○ Career or Technical Education

○ Other (please specify) __________

[If Section G, Item 1 is “” option 4, display items below.]

*3. Check the degree(s) or certificate(s) or endorsement(s) the participant received as a result of completing this grant-supported training (check all that apply):
□  Associate's Degree [Go to Section I, Question 4]

□  Bachelor's Degree [Go to Section I, Question 4]

□  Master's Degree [Go to Section I, Question 4]

□  Educational Specialist [Go to Section I, Question 4]

□  Doctoral Degree [Go to Section I, Question 4]

□  Postdoctoral Degree [Go to Section I, Question 4]
□  State, Tribal or Professional Credential/Certificate [Go to Section I, Question 5]
□ State-issued Endorsement [Go to Section I, Question 5]
□  Grantee-issued Endorsement [Go to Section I, Question 5]

[If both a “Go to question 4” and “Go to question 5” answer is checked, display both Questions 4 and 5]

*4. Select the major field of study associated with the participant’s degree: (select all that apply):

General Education

□  Administration
□  Elementary Education

□  Secondary Education

□  Social Work
□  School or Educational Psychology

□  Special Education

Subject Area

 □  Arts and Music

 □  Bilingual or English as a Second Language

 □  Early Childhood Education

 □  English or Language Arts

 □  Language Education (Native/Heritage/World Languages)

 □  Health or Physical Education

 □  Mathematics or Computer Science

 □  Natural Sciences

 □  Social Sciences

 □  Career or Technical Education

 □  Other (please specify) __________

*5. Select the area of certification attained by the participant after project training: (select all that apply):

General Education

□  Administration
□  Elementary Education

□  Secondary Education

□  Social Work
□  School or Educational Psychology

□  Special Education

Subject Area

 □  Arts and Music

 □  Bilingual or English as a Second Language

 □  Early Childhood Education

 □  English or Language Arts

 □  Language Education (Native/Heritage/World Languages)

 □  Health or Physical Education

 □  Mathematics or Computer Science

 □  Natural Sciences

 □  Social Sciences

 □  Career or Technical Education

 □  Other (please specify) __________

J. Information Verification and Submission

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

 □ Yes, all information available for this participant has been entered. I certify that all of the information I have provided is true and correct to the best of my knowledge. I understand that if I purposely give false or misleading information, I may be fined in an amount not less than $5,000 and not greater than $10,000, plus 3 times the amount of damages the Government sustains due to my false statement. - False Claims Act, 31 USC § 3729

Page 17