Grantee Scholar Record

Personnel Development Program

Data Collection System

Scholar Record

(Completed by Grantee)

OMB Control Number: 1820-0686

Expiration:

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 25 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 mandatory per the Individuals with Disabilities Education Act of 2004 (IDEA) and its corresponding, regulations, 34 CFR Part 304 Vol. 71 No. 107 June 5, 2006, printed in the Federal Register. 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 Record Form to this address.

Rules of Behavior for Department of Education-Sponsored Website

The Office of Special Education Program’s (OSEP) Personnel Development Program Data Collection System (PDPDCS) is an online data collection system designed to facilitate administration of the Personnel Development Program (PDP). This system collects employment and contact information from participating scholars to verify the fulfillment of their service obligation and assess program performance. Verifying service obligation requires collecting personally identifying information from grantees, scholars, and employers. This data collection has been authorized by the Individuals with Disabilities Education Act of 2004 (IDEA) and its corresponding requirements 34 CFR Part 304 printed in the Federal Register Volume 70, No. 57 March 25, 2005 and regulations Vol. 71, No. 107 June 5, 2006, and the Government Performance and Results Act of 1993, section 4.

Users of the PDPDCS must agree to certain conditions and agree to act to insure the accuracy and confidentiality of the information stored by the PDPDCS.

Violation of this policy will result in suspension of grantee access to the PDPDCS. Users representing grantees agree to:

• Maintain requested grant information, including grant contact information;

• Maintain PDPDCS accounts established to collect grant, grantee and scholar information by:

  • Protecting account login names and passwords;

  • Submitting scholar information as requested by PDPDCS;

  • Reviewing scholar information for accuracy; and

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

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

Privacy Act Notice

The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you. The authority for collecting the requested information about the scholar is part D of the Individuals with Disabilities Education Act, as amended by the Individuals with Disabilities Education Improvement Act of 2004 (IDEA). We request the scholar’s educational information pertinent to the OSEP scholarship grant received whether provided by the scholar, grantee, or other entity, including personally identifiable information (PII), under this authority in order to accurately track the scholar’s records and to differentiate the scholar’s financial obligation from other scholars who may have the same name. The scholar’s participation in the Office of Special Education (OSEP) Personnel Development Program (PDP) is voluntary and that giving us the scholar’s student educational information is voluntary, but you must provide the requested information, including the scholar’s PII, to participate. The information will be used to ensure that recipients of scholarships provided with funds under part D of the IDEA meet specific statutory and regulatory requirements, including service obligation fulfillment or repayment of financial obligation.

The information in you the scholar’s records may be disclosed to third parties as authorized under routine uses in the appropriate systems of records, either on a case-by-case basis, or, if the Department has complied with the computer matching requirements of the Privacy Act, under a computer matching agreement.

The routine uses of this information include sending the information, in the event of litigation, to the Department of Justice (DOJ), a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may also send this information to law enforcement agencies if the information is relevant to any enforcement, regulatory, investigative, or prosecutorial responsibility within the receiving entity’s jurisdiction. We may send information to the Department of Treasury and to credit agencies to verify the identity and location of the debtor and to the Department of Treasury, collection agencies, and employers of the scholarship recipient in order to service or collect on the debt. We may send information to members of Congress if you ask them to help you with questions related to this Program. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. If necessary for the Department to obtain advice from the DOJ, we can disclose information to the DOJ. We may disclose information to the DOJ or the Office of Management and Budget (OMB) to help us determine whether the Freedom of Information Act requires the disclosure of particular records. We can disclose records to contractors if we contract with an entity to perform functions that require the disclosure of the records. Finally, disclosures may be made to OMB as necessary under the requirements of the Credit Reform Act.

□ I agree to the terms.

Personnel Development Program

Data Collection System

Grantee Instructions for the Scholar Record

• Required Fields: Please complete the following questions for the scholar record. Required items are marked with an asterisk.

• Entering Scholars: Please note that scholars may only be entered into the PDPDCS under one OSEP grant at a time. If a scholar is funded sequentially under multiple OSEP funded grants, please exit the scholar from the first OSEP grant and assure that the scholar completes the Exit Certification from that OSEP grant. Then, the scholar and grantee must submit a new Pre-Scholarship Agreement under the next OSEP grant from which the scholar will receive funds. Please contact the Data Collection Center (DCC) HelpDesk at 1-800-285-6276 or [email protected] for further information, if needed.

• System Timing Out: You will be logged out of the system if you do not click the Save for Later or Save and Submit button after 30 minutes.

Saving and Submitting Records: To save a record for future editing or completion, click on the Save for Later button. This will create a pending record. When you have completed entry for a scholar, check the box in Section L. Then, click on the Save and Submit button. When the record is “submitted” for a scholar who has exited or completed the program, it CANNOT be edited. To edit those submitted records, please contact the DCC Helpdesk. However, records submitted for currently enrolled scholars can be edited.

• Scholar Access to System: Scholars are given access to the system when their records are submitted. If they have completed one or more academic years of training they are eligible to begin fulfilling their service obligation per 2006 Regulations, §304.30(f)(2).

Grant Award Number: [PRE-FILLED]

A. Identifying Information
*First Name			Middle Name		*Last Name
Maiden Name, if applicable:
*Social Security Number			--	--
*Date of Birth
*Primary E-mail Address
Do not use a university email address.
*Verify Primary E-mail Address
Alternative E-mail Address
Verify Alternative E-mail Address
* Required fields necessary to submit a record.

For grants awarded prior to FY 2012, please enter the 3-digit Scholar Data Report ID: __ __ __ (Only displayed for grants awarded in FY 2012 and earlier)

B. Contact Information
Permanent Address
*Address
Address Line 2
*City		*State		*Zip Code
*Home Phone		Cell Phone
Secondary Address
Address
Address Line 2
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 scholar, if necessary.

First Name

Last Name

E-mail Address

Verify E-mail Address

Address

Address Line 2

City

State

Zip Code

Home Phone

Other Phone

Please review and verify the information in Sections A, B, and C. Check the box below if there have been no changes in the last year.

□ No changes necessary.

D. Pre-Scholarship Agreement

Please upload a copy of the completed and signed Pre-Scholarship Agreement for this scholar.

OSEP requires grantees to use the U.S. Department of Education's OMB-approved template for Pre-Scholarship Agreements (#1820-0686). The grantee representative and scholar must complete and sign the document. The grantee representative signature must be the individual reflected in Box 3 of the Grant Award Notification (GAN).

DO NOT upload blank or unsigned agreements.

Files cannot exceed 6 MB in total between the files uploaded in Section D and Section K. If your files are larger than 6 MB in total you should compress the files or alter your scanning resolution. Best file sizes can be achieved by ensuring your scanner is set to a resolution no larger than 300 dpi. As well, set to "Black & White" or "Grayscale." Several compression tools are available, including PDF Optimizer for those users who have Adobe Acrobat 7 or later. Depending on the size of the file, the upload process may take several minutes. Acceptable file types include .doc, .docx, and .pdf. For assistance, please contact the Help Desk at [email protected] or 1-800-285-6276.

E. Scholar Demographic Information

1. What is this scholar’s gender?

• Female

• Male

2. Is this scholar of Hispanic or Latino origin?

• Yes

• No

3. What is this scholar’s race? Check all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

4. Does this scholar have a disability?

• Yes

• No

• Unknown

5. What is this scholar’s current age?

• Under 21

• 21-29

• 30-39

• 40-49

• 50 and over

F. Training and Employment Prior to Entry into OSEP Grant Training

*1. Check the degree(s) or certificate(s) or endorsement(s) held when the scholar entered this OSEP grant-supported training (check all that apply):

• High school diploma or equivalency [If only degree, go to Question 5]

• Associate’s Degree

• Bachelor's Degree

• Master's Degree

• Educational Specialist

• Doctoral Degree

• Postdoctoral Degree

• State or Professional Credential/Certificate

• State-issued Endorsement

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

• General education (If general education only, go to question 3)

• Special education or related services (Select training area under 2b)

• Outside the field of education (If outside of the field of education only, go to question 5)

2b. If special education or related services is checked under 2a above, select one special education and/or one related services training area that best describes the focus of the scholar’s degree/certificate/endorsement prior to entry into this OSEP grant-supported training.

Training Area	I. Special Education	Training Area	II. Related Services
	General special education, cross-categorical, generic, multi-categorical, or non-categorical		Audiology
			Counseling
			Educational diagnostician
	General special education, mild or moderate		Interpreter/ASL
	Low incidence disabilities/multiple disabilities/ severe intellectual disabilities		Music therapy
			Nursing
	Deafness and/or hard-of-hearing		Occupational therapy
	Visual impairment and/or blindness		Orientation & mobility
	Deaf/blindness		Paraprofessional
	Combined studies: general education and special education		Physical therapy
			Psychology
	Developmental delay		Rehabilitation counseling
	Specific learning disabilities		School counseling
	Speech/language impairment		Speech/language
	Emotional disturbance/behavioral disorders		Social work
	Autism		Therapeutic recreation
	Traumatic brain injury		Work experience coordinator (Employment transition specialist)
	Intellectual disability: mild/moderate
	Other health impairment
	Physical impairment/orthopedic impairment
	Adapted physical education
	Assistive technology
	Bilingual special education/ESL/TESOL
	Early intervention/early childhood special education/early childhood
	Special education for youth in correctional facilities
	Secondary transition

2c. If appropriate, select up to three additional training areas to provide more detailed information about the scholar’s focus of training prior to entry into this OSEP grant-supported training.

Training Area	I. Special Education	Training Area	II. Related Services
	General special education, cross-categorical, generic, multi-categorical, or non-categorical		Audiology
			Counseling
			Educational diagnostician
	General special education, mild or moderate		Interpreter/ASL
	Low incidence disabilities/multiple disabilities/ severe intellectual disabilities		Music therapy
			Nursing
	Deafness and/or hard-of-hearing		Occupational therapy
	Visual impairment and/or blindness		Orientation & mobility
	Deaf/blindness		Paraprofessional
	Combined studies: general education and special education		Physical therapy
			Psychology
	Developmental delay		Rehabilitation counseling
	Specific learning disabilities		School counseling
	Speech/language impairment		Speech/language
	Emotional disturbance/behavioral disorders		Social work
	Autism		Therapeutic recreation
	Traumatic brain injury		Work experience coordinator (Employment transition specialist)
	Intellectual disability: mild/moderate
	Other health impairment
	Physical impairment/orthopedic impairment
	Adapted physical education
	Assistive technology
	Bilingual special education/ESL/TESOL
	Early intervention/early childhood special education/early childhood
	Special education for youth in correctional facilities
	Secondary transition

3. Has this scholar received funding under a different OSEP training grant?

• Yes (Please specify grant number _________________________)

• No

4. Was the scholar employed during the academic year, prior to entry into this OSEP grant-supported training?

• Yes

• No (Go to Section G)

5. Choose one type of employment that best describes the pre-entry position of this scholar:

• Special education teacher (including positions in inclusive settings, e.g., as a co-teacher)

• General education teacher (not special education)

• Early interventionist, early childhood special educator, or early childhood educator

• Special education paraprofessional/aide

• General education paraprofessional/aide (not special education)

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

• Related service provider delivering early intervention or early childhood special education services

• Related or supportive service provider 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) (If selected, go to Section G

• Other, within education (please specify)

• Outside the field of education (If selected, go to Section G)

G. Current Training Program Information

*1. Date scholar enrolled in OSEP training program: __________ (mm/dd/yyyy)

Please provide the date the scholar enrolled in the OSEP-funded training program, which may or may not have been the date the scholar began receiving funding through the grant. This date must match the date of enrollment on the Pre-scholarship Agreement.

*2. Check the degree(s) or certificate(s) or endorsement(s) the scholar is pursuing through this special education or related services training grant: (Check all that apply)

• Associate’s degree

• Bachelor’s degree

• Master’s degree

• Educational specialist

• Doctoral degree

• Postdoctoral degree

• State or professional credential/certificate

• State-issued endorsement

*3. For what age(s) or grades of children does the program train the scholar to serve? (Check all that apply)

• Early intervention (infants and toddlers)

• Early childhood (preschool, ages 3 – 5, ages 3 – 8)

• Elementary (grades K – 6^th, K – 8^th, PreK – 6^th, PreK – 8^th)

• Middle/Jr. High school (grades 6^th – 8^th, 7^th – 9^th)

• High school (grades 9^th – 12^th, 10^th – 12^th)

• Post-secondary age/young adult (18 – 22 years, 18 – 25 years)

*4a. Select one special education and/or one related services training area that best describes the training focus for which the scholar is enrolled.

Training Area	I. Special Education	Training Area	II. Related Services
	General special education, cross-categorical, generic, multi-categorical, or non-categorical		Audiology
			Counseling
			Educational diagnostician
	General special education, mild or moderate		Interpreter/ASL
	Low incidence disabilities/multiple disabilities/ severe intellectual disabilities		Music therapy
			Nursing
	Deafness and/or hard-of-hearing		Occupational therapy
	Visual impairment and/or blindness		Orientation & mobility
	Deaf/blindness		Paraprofessional
	Combined studies: general education and special education		Physical therapy
			Psychology
	Developmental delay		Rehabilitation counseling
	Specific learning disabilities		School counseling
	Speech/language impairment		Speech/language
	Emotional disturbance/behavioral disorders		Social work
	Autism		Therapeutic recreation
	Traumatic brain injury		Work experience coordinator (Employment transition specialist)
	Intellectual disability: mild/moderate
	Other health impairment
	Physical impairment/orthopedic impairment
	Adapted physical education
	Assistive technology
	Bilingual special education/ESL/TESOL
	Early intervention/early childhood special education/early childhood
	Special education for youth in correctional facilities
	Secondary transition

Notice to 325D (Leadership) grantees: If the special education and related services areas above are not appropriate for the training focus of your grant, please provide a brief description of the scholar’s training focus below.

4b. If appropriate, select up to three additional training areas to provide more detailed information about the scholar’s focus of training.

Training Area	I. Special Education	Training Area	II. Related Services
	General special education, cross-categorical, generic, multi-categorical, or non-categorical		Audiology
			Counseling
			Educational diagnostician
	General special education, mild or moderate		Interpreter/ASL
	Low incidence disabilities/multiple disabilities/ severe intellectual disabilities		Music therapy
			Nursing
	Deafness and/or hard-of-hearing		Occupational therapy
	Visual impairment and/or blindness		Orientation & mobility
	Deaf/blindness		Paraprofessional
	Combined studies: general education and special education		Physical therapy
			Psychology
	Developmental delay		Rehabilitation counseling
	Specific learning disabilities		School counseling
	Speech/language impairment		Speech/language
	Emotional disturbance/behavioral disorders		Social work
	Autism		Therapeutic recreation
	Traumatic brain injury		Work experience coordinator (Employment transition specialist)
	Intellectual disability: mild/moderate
	Other health impairment
	Physical impairment/orthopedic impairment
	Adapted physical education
	Assistive technology
	Bilingual special education/ESL/TESOL
	Early intervention/early childhood special education/early childhood
	Special education for youth in correctional facilities
	Secondary transition

Please review and verify the information in Section G Items 1 through 4. Check the box below, if there have been no changes in the last year.

□ No changes necessary.

Note: Section G, Items 5 and 6 must be completed annually for scholars until they exit prior to completing the program or graduate/complete the program. Please complete these items for each year the scholar was actively enrolled in the program, even if he/she did not receive funding through the grant that year. A scholar is considered actively enrolled in the program if the scholar is working toward the degree/certificate/endorsement your OSEP-supported grant was designed to support. An actively enrolled scholar should be taking courses, completing an internship, working on a dissertation, or performing other similar activities required for completion.

*5. During the current or most recent grant budget period, was this scholar considered by your institution to be a full-time or part-time scholar?

Budget Period	Full-time scholar, even if the scholar worked full-time or part-time	Part-time scholar (anything less than full-time)	Not enrolled in the program
[PRELOAD DATES FY 1]	Full-time scholar	Part-time scholar	Not enrolled in the program
[PRELOAD DATES FY 2]	Full-time scholar	Part-time scholar	Not enrolled in the program
[PRELOAD DATES FY 3]	Full-time scholar	Part-time scholar	Not enrolled in the program
[PRELOAD DATES FY 4]	Full-time scholar	Part-time scholar	Not enrolled in the program
[PRELOAD DATES FY 5]	Full-time scholar	Part-time scholar	Not enrolled in the program
[PRELOAD DATES NCE 1]	Full-time scholar	Part-time scholar	Not enrolled in the program
[PRELOAD DATES NCE 2]	Full-time scholar	Part-time scholar	Not enrolled in the program

*6. Specify the total amount of funding this scholar received directly from this OSEP-supported training grant during the current or most recent grant budget period. In calculating the total amount, include any training stipend funds used for tuition and fees, scholar stipends, books, travel in conjunction with training assignments, and other associated training expenses. Please enter $0 for a scholar who was enrolled in the grant program but did not receive funding during the current budget period.

Budget Period	Scholar Funding Amount
[PRELOAD DATES FY 1]	$
[PRELOAD DATES FY 2]	$
[PRELOAD DATES FY 3]	$
[PRELOAD DATES FY 4]	$
[PRELOAD DATES FY 5]	$
[PRELOAD DATES NCE 1]	$
[PRELOAD DATES NCE 2]	$
Total	$[SUM ABOVE]

 H. Employment Information During OSEP Grant Program

For each budget period the scholar was enrolled in the program, regardless of whether

or not the scholar received funding that year, please enter information about the

scholar’s employment during the budget period. A scholar is considered enrolled in the

program if the scholar is working toward the degree/certificate/endorsement your OSEP-

supported grant was designed to support. An enrolled scholar should be taking courses,

completing an internship, working on a dissertation, or performing other similar activities

required for program completion.

Budget Period	Employment Information
[PRELOAD DATES Year 1]	Employed: Yes	No	Not enrolled in the program
[PRELOAD DATES Year 2]	Employed: Yes	No	Not enrolled in the program
[PRELOAD DATES Year 3]	Employed: Yes	No	Not enrolled in the program
[PRELOAD DATES Year 4]	Employed: Yes	No	Not enrolled in the program
[PRELOAD DATES Year 5]	Employed: Yes	No	Not enrolled in the program
[PRELOAD DATES NCE 1]	Employed: Yes	No	Not enrolled in the program
[PRELOAD DATES NCE 2 ]	Employed: Yes	No	Not enrolled in the program

2. [If yes] Average number of hours per week of employment:

_______ (Round to the nearest hour)

*3. Is this position:

• Same position held before entry to this OSEP grant-supported training

• Same position held in previous budget period (Note: If this position is the same position held before entry, please select the response above.)

• Different or new position (Proceed to question 4)

4. Choose one type of employment that best describes this scholar’s position:

• Special education teacher (including positions in inclusive settings, e.g., as a co-teacher)

• General education teacher (not special education)

• Early interventionist, early childhood special educator, or early childhood educator

• Special education paraprofessional/aide

• General education paraprofessional/aide (not special education)

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

• Related service provider delivering early intervention or early childhood special education services

• Related or supportive service provider in a school setting

• Related or supportive service provider in a non-school setting

• 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)

• Outside the field of education

 I. Scholar Status

Please indicate the appropriate program status of the scholar below. You must complete all subquestions for the option selected.

1. *Scholar program status:
Select the most appropriate option below.

○ The scholar is still enrolled in the program and is currently receiving OSEP funding.

○ The scholar is still enrolled in the program but is no longer receiving OSEP funding because:

Please specify other reason scholar is no longer receiving OSEP funding but is still enrolled.

___________________________________________________________

Is it expected that the scholar will be enrolled in a program supported by an OSEP grant at a future date?
○ Yes

○  No

○  Don’t know

○ The scholar exited/graduated/completed the program

Please enter the date of exit/graduation/completion.

__________ (mm/dd/yyyy)

Please note: The Exit Certification must be completed, signed and uploaded into PDPDCS within 30 days of exit from the program.

○ The scholar exited without graduating/completing the program.

Please enter the date of exit without completion: __________ (mm/dd/yyyy)

What are the reason(s) that the scholar is no longer enrolled in this program? (Check all that apply)

□	Transferred to another training program in special education or related services
□	Transferred to another program NOT in special education or related services
□	Financial stress or burden
□	Health (physical/emotional) of self or family member
□	Moved
□	Obtained employment
□	Other personal reasons
□	Poor academic performance
□	Poor practicum/field-based performance
□	OSEP funds terminated due to OSEP grant ending

Is it expected that the scholar will be enrolled in a program supported by an OSEP grant at a future date?
○ Yes
○ No
○ Don’t know

Please note: The Exit Certification must be completed, signed and uploaded into PDPDCS within 30 days of exit from the program.

2. Program Duration:

Select the most appropriate option below.

○ This program is less than one academic year in duration.

○ This program is one academic year or more in duration, but the scholar has not yet completed one academic year of training.

○ This program is one academic year or more in duration and the scholar completed one academic year of training on __________ (mm/dd/yyyy). (This date should be based on the date the scholar enrolled in the training program, which may or may not be the date the scholar began receiving funding through the grant.)

3. * Accumulated academic years of funding:
Enter durations less than one academic year as decimals. For example, 0.5 is half of one academic year of funding. See FAQ #2, at https://pdp.ed.gov/OSEP/Home/faq2006#2, for more information on accumulated academic years of funding.

4. Total service obligation in months: (prepopulated by the PDPDCS)

This amount was calculated by multiplying accumulated academic years of funding by 24 months, i.e., 2 years of service obligation for every academic year of scholarship support equals 48 months (or four years) of service obligation.

5. Date by which service obligation must be completed: (prepopulated by the PDPDCS)

This date was calculated by adding the total service obligation (accumulated academic years of funding multiplied by 24 months, i.e., 2 years of service obligation for every academic year of scholarship support) and the additional five years to the date to complete or exit the training.

J. Scholar Exit Information

*1.What degree(s) or certificate(s) or endorsement(s) did this scholar receive as a result of completing this OSEP grant-supported training: (Check all that apply)

• Associate’s degree

• Bachelor’s degree

• Master’s degree

• Educational specialist

• Doctoral degree

• Postdoctoral degree

• State or professional credential/certificate

• State-issued endorsement

• Course completion only [only displayed for grants awarded in FY 2009 or earlier]

*2a. Select one special education and/or one related services training area that best describes the training focus of the degree(s) or certificate(s) or endorsements(s) that this scholar received from this OSEP grant-supported training.

Training Area	I. Special Education	Training Area	II. Related Services
	General special education, cross-categorical, generic, multi-categorical, or non-categorical		Audiology
			Counseling
			Educational diagnostician
	General special education, mild or moderate		Interpreter/ASL
	Low incidence disabilities/multiple disabilities/ severe intellectual disabilities		Music therapy
			Nursing
	Deafness and/or hard-of-hearing		Occupational therapy
	Visual impairment and/or blindness		Orientation & mobility
	Deaf/blindness		Paraprofessional
	Combined studies: general education and special education		Physical therapy
			Psychology
	Developmental delay		Rehabilitation counseling
	Specific learning disabilities		School counseling
	Speech/language impairment		Speech/language
	Emotional disturbance/behavioral disorders		Social work
	Autism		Therapeutic recreation
	Traumatic brain injury		Work experience coordinator (Employment transition specialist)
	Intellectual disability: mild/moderate
	Other health impairment
	Physical impairment/orthopedic impairment
	Adapted physical education
	Assistive technology
	Bilingual special education/ESL/TESOL
	Early intervention/early childhood special education/early childhood
	Special education for youth in correctional facilities
	Secondary transition

Notice to 325D (Leadership) grantees: If the special education and related services areas above are not appropriate for the training focus of your grant, please provide a brief description of the training focus of the scholar’s degree(s) or certificate(s) or endorsements(s) below.

2b. If appropriate, select up to three additional training areas to provide more detailed information about the scholar’s focus of training.

Training Area	I. Special Education	Training Area	II. Related Services
	General special education, cross-categorical, generic, multi-categorical, or non-categorical		Audiology
			Counseling
			Educational diagnostician
	General special education, mild or moderate		Interpreter/ASL
	Low incidence disabilities/multiple disabilities/ severe intellectual disabilities		Music therapy
			Nursing
	Deafness and/or hard-of-hearing		Occupational therapy
	Visual impairment and/or blindness		Orientation & mobility
	Deaf/blindness		Paraprofessional
	Combined studies: general education and special education		Physical therapy
			Psychology
	Developmental delay		Rehabilitation counseling
	Specific learning disabilities		School counseling
	Speech/language impairment		Speech/language
	Emotional disturbance/behavioral disorders		Social work
	Autism		Therapeutic recreation
	Traumatic brain injury		Work experience coordinator (Employment transition specialist)
	Intellectual disability: mild/moderate
	Other health impairment
	Physical impairment/orthopedic impairment
	Adapted physical education
	Assistive technology
	Bilingual special education/ESL/TESOL
	Early intervention/early childhood special education/early childhood
	Special education for youth in correctional facilities
	Secondary transition

3. Did the scholar take an exam or measure to demonstrate knowledge and skills prior to completing this OSEP funded-training program?

• Yes (If selected, go to question 4)

• No (If selected, go to Section K)

• Don’t know (If selected, Section K)

4a-e. Please select the exam or measure the scholar took to demonstrate knowledge and skills.

Drop Down List of Measures (See Appendix A for complete list)

5a-e. Did the scholar pass this exam or measure?

• Yes

• No

• Don’t know

• Not applicable, our state does not set a passing score.

6a-d. Did the scholar take any other exam(s) or measure(s) to demonstrate knowledge and skills prior to completing this OSEP-funded training program?

• Yes (If selected, repeat questions 4 to 6 until no other measures, up to 5 total)

• No (If selected, go to Section K)

• Don’t know (If selected, go to Section K)

K. Service Obligation Information and Exit Certification

Please upload a copy of the completed and signed Exit Certification for this scholar within 30 days of exit from the program (either prior to completion or at completion of program).

OSEP requires grantees to use the U.S. Department of Education's OMB-approved template for the Exit Certification form (#1820-0686). The grantee representative and scholar must complete and sign the document. The grantee representative signature must be the individual reflected in Box 3 of the Grant Award Notification (GAN).

DO NOT upload blank or unsigned agreements.

Files cannot exceed 6 MB (in total) between the files uploaded in Section D and Section K. If your files are larger than 6 MB (in total) you should compress the files or alter your scanning resolution. Best file sizes can be achieved by ensuring that your scanner is set to a resolution no larger than 300 dpi. As well, set your scanner to "Black & White" or "Grayscale." Several compression tools are available, including PDF Optimizer for those users who have Adobe Acrobat 7 or later. Depending on the size of the file, the upload process may take several minutes. Acceptable file types include .doc, .docx, and .pdf. For assistance, please contact the Help Desk at [email protected] or 1-800-285-6276.

L. Information Verification

• Saving and Submitting Records: To save a record for future editing or completion, click on the Save for Later button. This will create a pending record. When you have completed entry for a scholar, check the box below. Then, click on the Save and Submit button. When the record is “submitted,” for a scholar who has exited or completed the program, it CANNOT be edited. To edit those submitted records, please contact the DCC Helpdesk. However, records submitted for currently enrolled scholars can be edited.

 □   Yes, all information available for this scholar 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.

Appendix A: List of Measures of Knowledge and Skills

The following options will be presented in two dropdown menus. The first drop down menu will contain the main options. The second drop down menu will dynamically populate with the secondary list based on the current selection in the first.

Category	Specific Assessment of Knowledge and Skills
Grantee specific test	Comprehensive Exams Defense of Dissertation Final Oral Exam for Master's Degree Portfolio Practicum Supervisor evaluation Teaching Performance Assessment Thesis Other Specify _________________________
National organization test	Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP) Certification Exam Adapted Physical Education National Standards (APENS) Exam American Physical Therapy Association (APTA) Pediatric Specialist Certification American Sign Language Teachers Association (ASLTA) Evaluation Interview Board Certified Behavior Analyst (BCBA) Exam Educational Interpreter Performance Assessment (EIPA) National Blindness Professional Certification Board (NBPCB) National Orientation and Mobility Certification Exam National Board for Professional Teaching Standards (NBPTS) Certificate National Board for the Certification of Occupational Therapists (NBCOT) Certification National Counselor Examination (NCE) The National Council for Therapeutic Recreation Certification (NCTRC) The National Physical Therapy Examination (NPTE) Reading Instruction Competence Assessment (RICA) Registry of Interpreters for the Deaf (RID) Certificate of Interpretation and Certificate of Transliteration (CI/CT) Registry of Interpreters for the Deaf (RID)/National Association of the Deaf (NAD)-National Interpreter Certification Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) Assistive Technology Practitioner (ATP) Sign Language Proficiency Interview (SLPI) Other Specify _________________________
PRAXIS II	Audiology Early Childhood: Content Knowledge Early Childhood Education Education of Deaf and Hard of Hearing Students Education of Exceptional Students: Core Content Knowledge Education of Exceptional Students: Learning Disabilities Education of Exceptional Students: Mild to Moderate Disabilities Education of Exceptional Students: Severe to Profound Disabilities Education of Young Children Educational Leadership: Administration and Supervision Elementary Education: Content Area Exercises Elementary Education: Content Knowledge Elementary Education: Curriculum, Instruction, and Assessment English Language, Literacy, and Composition: Content Knowledge Fundamental Subjects: Content Knowledge Interdisciplinary Early Childhood Education Introduction to the Teaching of Reading Middle School: Content Knowledge Middle School English Language Arts Middle School Mathematics Pre-Kindergarten Education Principles of Learning and Teaching: Early Childhood Principles of Learning and Teaching: Grades K-6 Principles of Learning and Teaching: Grades 5-9 Principles of Learning and Teaching: Grades 7-12 Reading Across the Curriculum: Elementary Reading Across the Curriculum: Secondary School Psychologist Special Education: Application of Core Principles Across Categories of Disability Special Education: Knowledge-delivered Core Principles Special Education: Preschool/Early Childhood Special Education: Teaching Students with Behavioral Disorders/Emotional Disturbances Special Education: Teaching Students with Learning Disabilities Special Education: Teaching Students with Mental Retardation Speech Communication: Content Knowledge Speech-Language Pathology Teaching Foundations: Mathematics Teaching Foundations: English Teaching Speech to Students with Language Impairments Teaching Students with Visual Impairments Other Specify _________________________
State specific test	Alabama (AL) Alabama Prospective Teacher Testing Program (APTTP)/Alabama WorkKeys Applied Mathematics Reading for Information Writing Arizona (AZ) Arizona Educator Proficiency Assessment (AEPA) Professional Knowledge: Early Childhood Professional Knowledge: Elementary Professional Knowledge: Secondary Subject Knowledge: Early Childhood Education Subject Knowledge: Elementary Education Subject Knowledge: Special Education: Cross-categorical Subject Knowledge: Special Education: Early Childhood Subject Knowledge: Special Education: Emotional Disability Subject Knowledge: Special Education: Hearing Impaired Subject Knowledge: Special Education: Learning Disability Subject Knowledge: Special Education: Mental Retardation Subject Knowledge: Special Education: Orthopedic Impairments/Other Health Impairments Subject Knowledge: Special Education: Severely and Profoundly Disabled Subject Knowledge: Special Education: Speech and Language Impaired Subject Knowledge: Special Education: Visually Impaired California (CA) California Basic Educational Skills Test (CBEST) California Subject Examinations for Teachers (CSET) Multiple Subjects I Multiple Subjects II American Sign Language (ASL) I American Sign Language (ASL) II American Sign Language (ASL) III Performance Assessment for California Teachers (PACT) California Teaching Performance Assessment (CalTPA) Fresno Assessment of Student Teachers (FAST) Colorado (CO) Program for Licensing Assessments for Colorado Educators (PLACE) Administrator Art Basic Skills Drama Early Childhood Education Early Childhood Special Education Elementary Education English Health Linguistically Diverse Linguistically Diverse Bilingual Education Mathematics Music Physical Education Principal Reading Specialist Reading Teacher School Counselor School Social Worker Science Social Studies Spanish Special Education Generalist Special Education: Severe Needs- Deaf/Hard of Hearing Special Education: Severe Needs-Visually Impaired Speech Florida (FL) Florida Teacher Certification Examinations (FTCE) General Knowledge Test (GK) Professional Education Test (PEd) Subject Area Examinations (SAE): Elementary Education K-6 Subject Area Examinations (SAE): English 6-12 Subject Area Examinations (SAE): Exceptional Student Education K-12 Subject Area Examinations (SAE): Hearing Impaired K-12 Subject Area Examinations (SAE): Mathematics Subject Area Examinations (SAE): Middle Grades English 5-9 Subject Area Examinations (SAE): Mathematics 5-9 Subject Area Examinations (SAE): Prekindergarten/Primary PK-3 Subject Area Examinations (SAE): Preschool Education Birth-Age 4 Subject Area Examinations (SAE): Reading K-12 Subject Area Examinations (SAE): Speech-Language Impaired K-12 Subject Area Examinations (SAE): Visually Impaired K-12 Florida Educational Leadership Examination (FELE) Florida Registry of Interpreters for the Deaf Quality Assurance Test Georgia (GA) Georgia Assessments for the Certification of Educators (GACE) Basic Skills Assessment Reading Mathematics Writing Content Assessments American Sign Language Art Education Birth Through Five Biology Early Childhood Education Early Childhood Special Education General Curriculum English Mathematics Middle Grades Language Arts Middle Grades Mathematics Middle Grades Reading Reading School Psychology Special Education Academic Content Concentrations Special Education Adapted Curriculum Special Education Deaf Education Special Education General Curriculum Professional Pedagogy Assessment Educational Leadership Assessment Paraprofessional Assessment Illinois (IL) Assessment of Professional Teaching (APT) Early Childhood (Birth to Grade 3) Elementary (K-9) Secondary (6-12) Special (K-12) or (P-21) Content-Area Tests Director of Special Education Early Childhood Education Early Childhood Special Education Elementary/Middle Grades English Language Arts Learning Behavior Specialist I Mathematics Reading Specialist Reading Teacher School Psychology School Social Worker Special Education General Curriculum test Speech-Language Pathologist: Nonteaching Speech-Language Pathologist: Teaching Teaching of Students Who Are Blind or Visually Impaired Teaching of Students Who Are Deaf or Hard of Hearing Learning Behavior Specialist II (LBS II) Tests Behavior Intervention Specialist Bilingual Special Education Specialist Curriculum Adaptation Specialist Deaf-Blind Specialist Multiple Disabilities Specialist Technology Specialist Transition Specialist Massachusetts (MA) Massachusetts Test for Educator Licensure (MTEL) Communication and Literacy Skills test Academic (PreK–12) subject matter tests Early Childhood English Foundations of Reading General Curriculum Mathematics Mathematics (Elementary) Mathematics (Middle School) Middle School Humanities Reading Specialist Vocational Technical Literacy Skills Test Adult Basic Education test Michigan (MI) Michigan Test For Teacher Certification (MTTC) Autism Spectrum Disorder Basic Skills Behavioral Studies Bilingual Education Biology Chemistry Cognitive Impairment Communication Arts (Secondary) Early Childhood Education Earth/Space Science Elementary Education Emotional Impairment English English as a Second Language Fine Arts Guidance Counselor Health Health, Physical Education, and Recreation Hearing Impaired History Humanities Integrated Science (Elementary) Integrated Science (Secondary) Language Arts (Elementary) Learning Disabilities Mathematics (Elementary) Mathematics (Secondary) Middle Level Music Music Education Physical Education Physical or Other Health Impairment Physical Science Physics Psychology Reading Reading Specialist Social Studies Speech and Language Impaired Visual Arts Education Visually Impaired Minnesota (MN) Minnesota Teacher Licensure Examinations (MTEL) Basic Skills Pedagogy: Early Childhood (Birth to Grade 3) Pedagogy: Elementary (Grades K-6) Pedagogy: Secondary (Grades 5-12) Content Area Tests: Early Childhood Education (Birth to Grade 3) Content Area Tests: Elementary Education (Grades K-6) Content Area Tests: Mathematics (Grades 5-12) Content Area Tests: PrePrimary (Age 3 to PreKindergarten) Content Area Tests: Reading Teacher Content Area Tests: Special Education Core Skills (Birth to Age 21) Nebraska (NE) Nebraska Commission for the Deaf and Hard of Hearing Quality Assurance Screening Test (QAST) New Mexico (NM) New Mexico Assessment of Teacher Basic Skills New Mexico Assessment of Teacher Competency (Elementary OR Secondary) New Mexico Content Knowledge Assessment in Special Education New York (NY) New York State Teacher Certification Examinations (NYSTCE) Liberal Arts and Science Test (LAST) Assessment of Teaching Skills (ATS-W) Elementary Secondary Bilingual Education Assessment (BEA) Content Specialty Tests (CSTs) American Sign Language Biology Blind and Visually Impaired Chemistry Deaf and Hard of Hearing Earth Science English Language Arts English to Speakers of Other Languages (ESOL) Health Education Literacy Mathematics Multi-Subject Music Physical Education Physics Social Studies Students with Disabilities Theatre Visual Arts Communication and Quantitative Skills Test (CQST) Assessment of Teaching Skills-Performance (ATS-P) Oklahoma (OK) Oklahoma General Education Test (OGET) Oklahoma Professional Teaching Examination (OPTE) Oklahoma Subject Area Tests (OSAT) Advanced Mathematics Art Biological Sciences Blind/Visual Impairment Chemistry Deaf/Hard of Hearing Early Childhood Education Earth Science Elementary Education Subtest 1: Reading/Language Arts Elementary Education Subtest 2: Social Studies/Mathematics/Science/Health, Fitness and the Arts Elementary Principal Specialty Test English English as a Second Language Instrumental/General Music Middle Level English Middle Level/Intermediate Mathematics Middle Level Principal Specialty Test Middle Level Science Middle Level Social Studies Mild-Moderate Disabilities Physical Education/Health/Safety Physical Science Physics Reading Specialist School Counselor School Psychologist Secondary Principal Specialty Test Severe-Profound/Multiple Disabilities Speech-Language Pathologist U.S. History/Oklahoma History/Government/Economics Vocal/General Music World History/Geography Oregon (OR) Oregon Educator Licensure Assessments (ORELA) Administrator Art Biology Chemistry Early Childhood Education English Language Arts English to Speakers of Other Languages (ESOL) Health Mathematics Middle Grades English Language Arts Middle Grades General Science Middle Grades Mathematics Middle Grades Social Studies Multiple Subjects Music Physics Physical Education Protecting Student and Civil Rights in the Educational Environment School Counselor Special Education Texas (TX) Texas Examinations of Educator Standards (TExES) Principal Pedagogy and Professional Responsibilities 4-8 Generalist 4-8 English Language Arts and Reading/Social Studies 4-8 Mathematics/Science 4-8 Mathematics 4-8 Science 4-8 English Language Arts and Reading 4-8 Social Studies 4-8 English as a Second Language (ESL)/Generalist 4-8 Pedagogy and Professional Responsibilities 8-12 English Language Arts and Reading 8-12 Social Studies 8-12 History 8-12 Mathematics 8-12 Science 8-12 Physical Science 8-12 Life Science 8-12 Chemistry 8-12 Mathematics/Physics 8-12 Reading Specialist School Counselor Educational Diagnostician English as a Second Language (ESL) Supplemental Health EC-12 Physical Education EC-12 Pedagogy and Professional Responsibilities EC-12 Special Education Supplemental Bilingual Education Supplemental Mathematics/Physical Science/Engineering Music EC-12 Art EC-12 Deaf and Hard of Hearing Visually Impaired/Braille American Sign Language Bilingual Target Language Proficiency Test (BTLPT) Bilingual Target Language Proficiency Test (BTLPT) Supplemental Guide Generalist EC-6 Bilingual Generalist EC-6 English as a Second Language (ESL)/Generalist EC-6 Pedagogy and Professional Responsibilities EC-6 Texas Assessment of Sign Communications (TASC) Texas Assessment of Sign Communications-American Sign Language (TASC-ASL) Virginia (VA) Virginia Communication and Literacy Assessment (VCLA) Virginia Quality Assurance Screening (VQAS) Virginia Reading Assessment (VRA) Early/Primary prek-3 Elementary Education prek-6 Special Education-General Curriculum Special Education-Hearing Impairments Special Education-Visual Impairments Washington (WA) Washington Educator Skills Test-Basic (WEST-B) Mathematics Reading Writing Washington Educator Skills Test-Endorsements (WEST-E) Bilingual Education Biology Chemistry Dance Earth and Space Science Early Childhood Education Early Childhood Special Education Elementary Education English Language Arts English Language Learner Health/Fitness History Mathematics Middle Level Humanities Middle Level Math Middle Level Science Music: Choral Music: General (neither Choral nor Instrumental) Music: Instrumental Physics Reading Science Social Studies Special Education Visual Arts Other Specify _________________________
Other test	Other Specify _________________________