Employment Verification Record

OMB Control Number: 1820-0686

Expiration:

Personnel Development Program

Data Collection System

Employment Verification Record

(Completed by Employer)

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 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 is voluntary. 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 Record to this address.

Rules of Behavior for U.S. Department of Education-Sponsored Website

The Personnel Development Program Data Collection System (PDPDCS) 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 scholars to verify the fulfillment of their service obligation and support program performance and improvement. Verifying service obligation requires collecting personally identifying information from Institutions of Higher Education, scholars, 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 PDPDCS must agree to certain conditions and agree to act to insure the accuracy and confidentiality of the information stored by the PDPDCS.

Employers using this system agree to:

• Maintain the confidentiality of requested employment information about scholars;

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

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

□ I agree to the terms.

Employment Verification Page 1

Welcome to the Personnel Development Program Data Collection System (PDPDCS). The scholar 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. Scholars are required to provide PDPDCS with annual updates about their employment in order for PDPDCS to track the fulfillment of their service obligation. For scholars to receive service obligation credit, their employment must be verified by an employer. Additional information about DCS and the service obligation is available on the PDPDCS Web site at https://pdp.ed.gov/OSEP.

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

Employer Information (fields are pre-filled)

*Organization Name: ______________________________

Department Name: ________________________________

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

Please provide the name of a supervisor at this job who can verify this employment information.

*First Name: *Last Name:

___________________________ __________________________

Supervisor’s Business Address

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ ___________________

*E-mail: *Verify E-mail:

_________________ ________________

Alternative E-mail: Verify Alternative E-mail:

_________________ ___________________

Fax: TTY:

_____________________ _____________________

Human Resource Manager Information

Please provide the name of a human resources manager at this job who can verify this employment information.

*First Name: *Last Name:

___________________________ __________________________

Human Resource Manager’s Business Address: 

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ ___________________

*E-mail: *Verify E-mail:

_________________ ________________

Alternative E-mail: Verify Alternative E-mail:

_________________ ___________________

Fax: TTY:

_____________________ _____________________

Name of person completing this form:

______________________________

Employment Verification Page 2.

Please review the information below.

Please select whether you AGREE or DISAGREE with the scholar's response to each question, provide a response to item #9, then click the Submit button at the bottom of the page. If you disagreed with the scholar’s response to any question, you will have the opportunity to describe the reason for your disagreement on the following page. An Employment Dispute Report will be sent to the scholar, and he or she will have the opportunity to revise and resubmit the employment information for verification based on your changes.

Employee Name: 

1. Was the scholar employed from _______________ to ____________?

Agree □ Disagree □

If you disagree, please explain:

PLEASE NOTE:

We understand that scholars may have begun employment prior to the date listed here.  However, according to program regulations, scholars may begin work in eligible employment following the completion of one academic year of training. Therefore, the PDPDCS only allows for dates of an employment position after the completion of one academic year of training. If a scholar began employment prior to their completion of one academic year of training, the date indicated above reflects only that employment that began after the completion of one academic year of training. Please verify that the scholar was employed during the dates listed above.

2a. Is/was this full time or part time employment (Full time as defined by you the employer and must be 30 hours or more per week)?

S cholar Answer:

Agree □ Disagree □

I f you disagree, please explain:

2b. If this employment is/was part-time, on average, how many hours does the scholar work per week at this job?

Scholar Answer:

Agree □ Disagree □

I f you disagree, please explain

3. Which of the following best describes the position?

Scholar Answer:

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

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

• Special education paraprofessional/aide

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

• Related or supportive 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)

• Other, within education (please specify____________________________)

Agree □ Disagree □

If you disagree, please explain:

[WHICH OF ITEMS 4, 5, OR 6 ARE DISPLAYED DEPENDS ON SCHOLARS RESPONSE TO ITEM 4.]

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


Scholar Answer:

• 50% or less

• At least 51%

Agree □ Disagree □

If you disagree, please explain:

5. Describe the percentage of special education students taught or served in this position.


Scholar Answer:

• 50% or less

• At least 51%

Agree □ Disagree □

If you disagree, please explain:

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

Scholar Answer:

• 50% or less

• At least 51%

Agree □ Disagree □

If you disagree, please explain:

7. Is the scholar certified/licensed for this position? Certified/licensed 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.

S cholar Response:

Agree □ Disagree □

If you disagree, please explain:

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

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

• Effective

• Less than effective

• Ineffective

• Not rated for this position

• Choose not to respond

If you checked DISAGREE next to any of the scholar’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 scholar, and he or

she will have the opportunity to revise and resubmit the employment information for verification based on your changes.

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.