Pre-Scholarship Agreement

OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

Paperwork Burden 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 30 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 required to obtain or maintain benefits (Individuals with Disabilities Education Act (IDEA) and its corresponding regulations 34 CFR Part 304). 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 Service Obligation Pre-Scholarship Agreement to this address.

Service Obligation Pre-Scholarship Agreement

For a Scholarship Received from a Personnel Development to Improve Services and Results for Children with Disabilities

Grant Awarded in Fiscal Year 2006 and Any Year Thereafter

Service Obligation Pre-Scholarship Agreement

Between

_____________________________

Name of Scholar

And

______________________________

Name of Grantee

Prior to granting a scholarship, the grantee will require each scholar to use the OMB-approved Pre-scholarship Agreement in which the scholar agrees to the terms and conditions set forth in the regulations published on June 5, 2006 implementing section 662(h) of IDEA (see 34 CFR part 304), including the requirement that the Secretary track the service obligations of scholarship recipients. The regulations and the Frequently Asked Questions (FAQs) are also available at http://www.serviceobligations.ed.gov/ProgramRegs2006.cfm, and http://www.serviceobligations.ed.gov/2006faq.cfm.

According to section 304.23(a), the Secretary may grant a deferral or an exception to the work or repayment requirements upon request, if a scholar or an obligee can provide sufficient evidence to substantiate eligibility.

The U.S. Department of Education’s address for purposes of this Pre-Scholarship Agreement is:

OSEP PDP Data Collection Center

Grants Awarded in FY2006 and Any Year Thereafter
US Department of Education

Office of Special Education Programs
1600 Research Blvd, RA 1297
Rockville, MD 20850

To Be Completed by the Grantee

Grant Award Number: H325

Grantee:

Project Title:

Course of Study or Program:

Project Director:

Date of Scholarship Assistance and Service Obligation Meeting:

Estimated total amount of training in academic years:

Estimated total amount of funding that will be provided:

Date of Enrollment:

Scholar Contact Information

Scholar Name:

Date of Birth:

Social Security Number:

Street Address:

City, State, Zip Code:

Telephone Number:

E-mail Address:

Alternate Scholar Contact Information

Name:

Relationship:

Street Address:

City, State, Zip Code:

Telephone Number:

E-mail Address:

To Be Completed by Scholar

I have read the Service Obligation Regulations, the FAQs and the statements (a) through (i) below:

1. Upon exiting the training program, I must subsequently maintain employment 1) on a full-time or full-time equivalent basis; and 2) for a period of at least two years for every academic year for which assistance was received;

2. The eligible employment through service obligation must be related to the training received; and

3. I must be employed in a position in which

1) At least 51 percent of the infants, toddlers, and children to whom I provide services are receiving special education, related services, or early intervention services from me;

2) I spend at least 51 percent of my time providing special education, related services, or early intervention services to infants, toddlers, and children with disabilities; or

3) If the position involves supervision including in the capacity of a principal, teaching at the postsecondary level, research, policy, technical assistance, program development, or administration, I spend at least 51 percent of my time performing work related to the training for which a Special Education -- Personnel Development to Improve Services and Results for Children with Disabilities program scholarship was received under section 662 of the Act.

4. I cannot repay my service obligation through eligible employment unless I have completed my academic training or have completed at least one academic year of training, and if I cannot repay through eligible employment, I must repay the total amount of funding I have received for my training;

5. If I do not fulfill my service obligation through eligible employment, I must repay the total amount of funding received for my training or a prorated amount if I have fulfilled a portion of my service obligation through eligible employment;

6. I will inform the US Department of Education of my intention to complete my service obligation either through eligible employment or by repaying the total amount of funding received within 30 days of completion of my training. I have provided the information requested of me in this Agreement to the grantee representative;

7. I have completed the Certification of Eligibility for Federal Assistance form (ED 80-0016);

8. I understand there is no guarantee of federal funding for the duration of my training; and

9. I have agreed to comply with the regulations for the Special Education -- Personnel Development to Improve Services and Results for Children with Disabilities program (see 34 CFR part 304), including the requirement to provide the information necessary to the Secretary to track my service obligation.

______________________________ _______________________________ ____________

Scholar Name Scholar Signature Date

(Please print)

To be Completed by Grantee Representative

I have met with the scholar and discussed the service obligation requirements and provided him/her with a copy of the regulations and the FAQs.

____________________________ ___________________­­­­­­­­________ ___________

Grantee Representative Name Grantee Representative Signature Date

(Please print)

Note: Upon enrollment, the completed Pre-scholarship Agreement must be directly entered into the Service Obligation database at http://serviceobligations.ed.gov.

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