Employment Verification Form

OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

Personnel Development Program Data Collection System: Employment Verification Form

(Completed by Employer)

OMB Control Number: 1820-0686

Expiration: xx/xx/xxxx

Public 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 10 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 required to obtain or retain benefit (Individuals with Disabilities Education Act). 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 Personnel Development Program Data Collection System (DCS) is an online data collection system designed to facilitate administration of the program by the Office of Special Education Programs at the U.S. Department of Education. This system collects employment and contact information from participating scholar/obligees to verify the fulfillment of their service obligation and assess program performance. 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 regulations printed in the Federal Register Volume 71 No. 107 June 5, 2006, and the Government Performance and Results Act of 1993, section 4.

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.

Employers using this system agree to:

• Maintain the confidentiality of requested employment information about scholars/obligees;

• Maintain control of secure links by adhering to workplace security safeguards; and

• Verify scholar/obligee employment within 30 days of the annual notification e-mail from DCS.

□ I agree to the terms.

Employment Verification Page 1

Welcome to the Personnel Development Program Data Collection System (DCS). The obligee listed below accepted a scholarship from a grant awarded to an Institution of Higher Education (IHE) by the U.S. Department of Education, Office of Special Education Programs (OSEP). These scholarships include a service obligation requirement of two (2) years of eligible employment for each year of IHE support. Obligees are required to provide DCS with annual updates about their employment in order for DCS to track the fulfillment of their service obligation. Additional information about DCS and the service obligation is available on the DCS Web site at http://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

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)

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 and describe the reason for your disagreement in the box provided. Once you have completed all questions, please click the “Proceed” button at the bottom of the 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 them and resubmit for your 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 program performance at OSEP.

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

Obligee Response :

If you disagree, please explain:

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

Obligee Response:

If you disagree, please explain:

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

Obligee Response:

If you disagree, please explain:

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

• Special education teacher

• Early intervention, early childhood, or early childhood service provider

• Special education paraprofessional/aide

• Early intervention, early childhood special education, or early childhood paraprofessional/aide

• Related or supportive service provider in early intervention, early childhood or in a school setting

• Related or supportive service provider in a non-school setting (e.g., child find services)

• Administrator/coordinator/supervisor (including the capacity of a principal)

• Instructional specialist

• Higher education (e.g., faculty, research assistant, practicum coordinator)

• Other, within education (please specify____________________________)

If you disagree, please explain:

Please review Questions 5 and 6 if the scholar selected one of the following answers for Question 4:

• Special education teacher

• Early intervention, early childhood, or early childhood service provider

• Paraprofessional/aid

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

• 50% or less

• At least 51%

If you disagree, please explain:

6. D escribe the percentage of special education students taught or served in this position.
   
   Disagree □
   Obligee Response:
   
   

• 50% or less

• At least 51%

I f you disagree, please explain:

7.  * Is the obligee "highly qualified/qualified/fully certified" for this position under Individuals with Disabilities Education Act (IDEA) and has not had certification or licensure requirements waived on an emergency, temporary or provisional basis? "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. ² Disagree □

Obligee Answer:

If you disagree, please explain:

This question is confidential and will not be shared with the obligee.

8. At this time, the oblige is rated on the (State, District, or School) performance appraisal system as:

• Effective

• Less than effective

• Ineffective

• Not rated for this position

1 PLEASE NOTE: The start date indicated in the employment record may not reflect the actual start date of employment. As per program regulations, scholars/obligees may begin work in eligible employment following the completion of one academic year of training. Therefore, the DCS only allows for start dates of an employment position after the completion of one academic year of training. Please verify that the scholar/obligee was employed during the dates listed above.

2 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.”