Scholar/Obligee Training and Employment Form

Personnel Development Program Data Collection System: Scholar/Obligee Employment Record Form

(Completed by Scholar/Obligee)

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 15 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 of 2004 (IDEA) and its corresponding requirements, 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 Scholar/Obligee Employment Record Form application to this address.

Rules of Behavior for Department of Education-Sponsored Website

The Personnel Development Program (PDP) Data Collection System (DCS) is an online data collection system designed to facilitate administration of the Personnel Development Program, in the Office of Special Education Programs at the US 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 corresponding regulations printed in the Federal Register Volume 71 No. 107 June 5, 2006, and the Government Performance and Results Act of 1993, section 4.

Scholars/obligees using this system agree to:

• Maintain requested contact and employment information

• Maintain their DCS accounts by:

  • Protecting account login names and passwords;

  • Submitting accurate information for current address, phone number, employment status and employer information; and

  • Using the DCS only to access their own information.

By agreeing to these Rules of Behavior, scholars/obligees agree to maintain the confidentiality of this information. Violation of this policy will result in suspension of scholar/obligee access to the DCS.

□ I agree to the terms.

Employment Record Form

Employment Information

The questions relating to your employment affect your obligation fulfillment status. You must answer every question to the best of your ability. Providing information that you know to be false may be punishable by law.

1. 1. Does your current or previous employment fulfill your service obligation?

• Yes

• No

Employment Information

2. 2. Is this position a substitute teaching position?

• Yes

• No

Organization Type
1. What type of organization is this?* Public School Residential School For-profit or Commercial Organization Federal Government Agency State or Local Government Agency	Private School Hospital College/University Non-Profit Organization Other, Please Specify:_____________

If respondent selects “Public School” above, display Common Core of Data search functionality, or proceed with open text fields.

Employer Information

You must provide the name, address, and phone number of the employer organization for this position. If your employment position is outside of the United States, please contact the DCS Helpdesk to report your employment information. You must list at least one supervisor or human resources manager who can verify your employment and provide his or her e-mail address. You will be asked on the next page to indicate which contact should be sent your employment record for verification.

*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

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 Information

Please note that past employment records cannot be edited once submitted for verification. Your employer will have 30 days from the date of submission to verify or dispute your employment information for this position. Current employment records can be edited. You will receive credit for current employment up to the date of last update. You cannot update your current employment record during your employer’s 30–day verification period until your employer verifies or disputes the record or the 30-day verification window expires. Also note that per 2006 Regulations §304.30(f)(2), you will not receive credit for work completed prior to the date when you completed one academic year of training.

Classroom teachers with 12 month contracts must indicate 12 months of employment to receive a year of service obligation credit. If you enter the start and end dates of the school year you will only receive credit for the number of months entered.

Question #7 does not affect your service obligation fulfillment status. This question is for measuring performance of the programs at the Office of Special Education Programs.

To save a record for later completion, please click the "Save For Later" button at the bottom of the page.

1. *Is this your current employment?

• Yes

• No

*When did this job begin? (mm/dd/yyyy) When did this job end? (mm/dd/yyyy)

Please note: past employment records cannot be edited once submitted.

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

• 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________________________)

3. *Is this a full or part-time position?

3a. Full Time (As defined by your Employer)

• This is a summer position

• This position has summers off

• This is a year round position

3b. Part Time

• If this employment is part-time, on average, how many hours does the scholar/obligee work per week at this job? ______

4. Select one special education and/or related services training area that best describes this employment position.

I. Special Education II. Related Services

□	General special education, cross-categorical, generic, multi-categorical, or non-categorical
□	General special education, mild or moderate
□	Low-incidence disabilities/multiple disabilities/severe disabilities
□	Combined studies: General education and special education
□	Developmental delay
□	Specific learning disabilities
□	Speech/language impairment
□	Emotional disturbance/behavioral disorders
□	Autism
□	Traumatic brain injury
□	Deafness and/or hard-of-hearing
□	Visual impairment and/or blindness
□	Deaf-blindness
□	Intellectual disability: Mild/moderate
□	Intellectual disability: Severe
□	Other health impairment
□	Physical impairment/orthopedic impairment
□	Adapted physical education
□	Assistive technology
□	Bilingual special education/ESL/TESOL
□	Early childhood/early intervention
□	Special education for youth in correctional facilities
□	Secondary transition

□	Audiology
□	Counseling
□	Educational diagnostician
□	Interpreter/ASL
□	Music therapy
□	Nursing
□	Occupational therapy
□	Orientation & mobility
□	Paraprofessional
□	Physical therapy
□	Rehabilitation counseling
□	School counseling
□	Psychology
□	Speech/language
□	Social work
□	Therapeutic recreation
□	Work experience coordinator (employment transition specialist)

If the special education and related services areas above are not appropriate for the training focus of your employment, please provide a brief description of the area of focus for this employment.

5. If appropriate, select up to three additional training areas to provide more detailed information about this employment position.

I. Special Education II. Related Services

□	General special education, cross-categorical, generic, multi-categorical, or non-categorical
□	General special education, mild or moderate
□	Low-incidence disabilities/multiple disabilities/severe disabilities
□	Combined studies: General education and special education
□	Developmental delay
□	Specific learning disabilities
□	Speech/language impairment
□	Emotional disturbance/behavioral disorders
□	Autism
□	Traumatic brain injury
□	Deafness and/or hard-of-hearing
□	Visual impairment and/or blindness
□	Deaf-blindness
□	Intellectual disability: Mild/moderate
□	Intellectual disability: Severe
□	Other health impairment
□	Physical impairment/orthopedic impairment
□	Adapted physical education
□	Assistive technology
□	Bilingual special education/ESL/TESOL
□	Early childhood/early intervention
□	Special education for youth in correctional facilities
□	Secondary transition

□	Audiology
□	Counseling
□	Educational diagnostician
□	Interpreter/ASL
□	Music therapy
□	Nursing
□	Occupational therapy
□	Orientation & mobility
□	Paraprofessional
□	Physical therapy
□	Rehabilitation counseling
□	School counseling
□	Psychology
□	Speech/language
□	Social work
□	Therapeutic recreation
□	Work experience coordinator (employment transition specialist)

Please answer the questions below that best describe the work you do in this position. Eligible employment must 1) fulfill at least one of the requirements listed in §304.30(e) of the 2006 Program Regulations; 2) provide compensation; and 3) if serving children, the children must fall under the definition of eligible children as described in IDEA 2004 section 602(3).

6. Please complete Questions 6a. and 6b. only if you selected one of the following answers for Question 2: Which of the following best describes the position?:

• Teacher

• Early intervention, early childhood, or early childhood service provider Paraprofessional/aide

If you did not select one of the above responses in Question 2, please complete Question 6c.

6a. *Describe the percentage of time spent teaching or serving special education students in this position.

• 50% or less

• At least 51%

6b. *Describe the percentage of special education students taught or served in this position.

• 50% or less

• At least 51%

6c. *Describe the percentage of time spent performing work related to the training for which the scholarship was received under section 662 of IDEA the Individuals with Disabilities Education Act of 2004 in this position.

• 50% or less

• At least 51%

7.  *Are you "highly qualified/qualified/fully certified" for this position under Individuals with Disabilities Education Act (IDEA) and have not had certification or licensure requirements waived on an emergency, temporary or provisional basis? Select the most appropriate answer.
   "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.

• {Highly qualified/qualified/fully certified}

• {Not highly qualified/Not qualified/Not fully certified}

• This state does not have requirements for certification/licensure for this position

• Not applicable to this type of employment position

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." 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.”

Please provide the name and the e-mail of the employer contact(s) you would like to receive the verification request: