Employment Verification Form

Indian Education Professional Development

Data Collection System

Employment Verification 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 10 minutes per employer, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 Employment Verification 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 requirement. 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 employer access to the DCS.

Employers using this system agree to:

• Maintain requested participant information, and

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

• Submitting accurate information for the participants’ employment status and employer information; and

• Using the DCS only to access their own information.

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

□ I agree to the terms.

Employment Verification Page 1

Welcome to the IEPD Data Collection System (DCS). The program participant listed below accepted funds from a grant awarded to an Institution of Higher Education (IHE) by the Department of Education’s Indian Education Professional Development Program (IEPD). The funds received by the participant included a service payback requirement. Participants are required to provide DCS with updates about their employment every 6 months in order for the IEPD to track the fulfillment of their service payback obligation. Additional information about DCS and the service payback is available on the DCS Web site at [INSERT LINK].

Please take a moment to verify the accuracy or to correct any inaccuracies of the information provided by the participant. 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!

Please note: while OIE is tracking participant employment in targeted schools with American Indian/Alaska Native enrollment of 5 percent or more, this is not to be considered a requirement for service payback. Eligible employment for service payback is any employment that is in the participant’s field of study and benefits Indian people (ESEA 7122 (h)(1)(A), 34 CFR 263.8(b)(1)).

Employee Name: [PRE-FILLED]

* Required fields necessary to submit a record. [ALL FIELDS ARE PRE-FILLED BASED ON PARTICIPANT’S RESPONSES. EMPLOYERS MAY EDIT FIELDS AS NECESSARY]

Employer Information

*Organization Name: ______________________________

(e.g., name of school district, name of government agency)

Department Name: ________________________________(e.g., school name, government department)

Organization Address

*Address Line 1: Address Line 2:

___________________________ __________________________

*City: *State: *Zip Code:

________________ ___________ ______-____

*Phone: Fax:

_________________ __________________

TTY:

_____________________

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:

_________________ __________________

*E-mail: *Verify E-mail:

_________________ ________________

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

_________________ ___________________

Fax: TTY:

_____________________ _______________

Human Resource Manager

*First: *Last:

___________________________ __________________________

Human Resource Manager’s Business Address: 

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ __________________

*E-mail: *Verify E-mail:

_________________ ________________

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

_________________ ___________________

Fax: TTY:

_____________________ _______________

Name of person completing this form

_______________________________

Employment Verification Page 2

Please review the information below.

If you AGREE with all of the participant’s responses, click the Submit button at the bottom of the page. If you DISAGREE with the participant'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 Submit” 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 Dispute Report will be provided to the participant and he or she will have the opportunity to accept your changes or revise and resubmit for verification.

Employee Name: [PRE-FILLED]

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

Participant Answer:

• Paraprofessional/Teacher Assistant/Teacher Aide

• Classroom Teacher

• Assistant Principal

• Principal

• Administrator – LEA (Local Education Agency)

• Administrator – SEA (State Education Agency)

• Administrator – TEA (Tribal Education Agency)

• Social Worker

• Ancillary Education Personnel

• Other, Please Specify:________________ Disagree □

*2. When did the participant begin his or her employment in this position? (mm/dd/yyyy)

Participant Answer: Disagree □

*3 a. Is the participant currently employed in this position?

Participant Answer: Disagree □

*3 b. If no, when did the participant end their employment in this position? (mm/dd/yyyy)

Participant Answer: Disagree □

*4. Is/was this full time or part time employment?

Participant Answer: Disagree □

*5. Is/was this a paid position?

Participant Answer: Disagree □

*6. Would this position be a paid position if funding were available?

Participant Answer: Disagree □

*7. Does the position have direct involvement with students/school administration?

Participant Answer: Disagree □

*8. Does/did the employment benefit American Indian/Alaska Native people?

Participant Answer: Disagree □

*9. What general education area best describes/described this position?

Participant Answer: Disagree □

General Education

• Administration

• Elementary Education

• Secondary Education

• Social Work

• School or Educational Psychology

• Special Education

*10. What subject area best describes/described this position?

Participant Answer: Disagree □

Subject Area

• Not Applicable

• 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) ____________________

*11. Please select the most appropriate grade span (check all that apply)

Participant Answer: Disagree □

 □  Pre-K

 □  K – 5

 □  6 – 8

 □  9 – 12

 □  Other (please specify) ____________________

*12. Is/was the participant ”State Qualified” for this position?

Participant Answer: Disagree □

If you checked DISAGREE next to any of the participant’s responses, please describe the reason for your disagreement on the following page. Please include what you believe to be the correct response. An Employment Dispute Report will be provided to the participant and he or she will have the opportunity to accept your changes or revise and resubmit for verification.

Page 1