Employment Verification Form

Indian Education Professional Development Grants Program: GPRA and Service Payback Data Collection

1810-0698 PD_employer_form 04182019

Employment Verification Form

OMB: 1810-0698

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1810-0698 can be found here:

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OMB Control Number: 1810-0698

Expiration: XX/XX/XXXX

Indian Education Professional Development Program

Data Collection System

Employment Verification Form

OMB Control Number: 1810-0698

Expiration: XX/XX/XX

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 employer, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Angela Hernandez-Marshall, Education Program Specialist, Office of Indian Education, U.S. Department of Education, 400 Maryland Ave SW, Room 3W113, Washington, DC 20202 or email [email protected] and reference the OMB Control Number 1810-0686. Note: Please do not return the completed Employment Verification Form to this address.

Rules of Behavior for Department of Education-Sponsored Website

The Indian Education Professional Development Program Data Collection System (PDPDCS) is an online data collection system designed to facilitate administration of the Indian Education PDP. This system collects employment and contact information from participants to verify the fulfillment of their payback requirement. Verifying payback requires collecting personally identifying information from grantees, participants, and employers. This data collection has been authorized by section 7122 of the Elementary and Secondary Education Act of 1965, as amended, and its corresponding regulations, 34 CFR Part 263, Subpart A.

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 employer access to the PDPDCS.

Employers using this system agree to:

Maintain requested participant information, and
Maintain PDPDCS accounts established to collect grant, participant, and employer information by:

Submitting accurate information for the participants’ employment status and employer information; and
Using the PDPDCS only to access their own information.

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

□ I agree to the terms.

Employment Verification Page 1

Welcome to the Indian Education Professional Development Program Data Collection System (PDPDCS). The program participant listed below accepted funds from a grant awarded to an Institution of Higher Education (IHE) by the Department of Education’s Indian Education Professional Development Program (IEPDP). In receiving funds,the participant agreed to a service payback requirement. Participants are required to provide PDPDCS with updates about their employment every 6 months in order for PDPDCSto track the fulfillment of their service payback obligation. Additional information about PDPDCS and the service payback is available on the PDPDCS Web site at https://pdp.ed.gov/oie.

Please take a moment to verify the accuracy or to correct any inaccuracies of the information provided by the participant. 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: [PRE-FILLED]

* Required fields necessary to submit a record. [ALL FIELDS ARE PRE-FILLED BASED ON PARTICIPANT’S RESPONSES. EMPLOYERS MAY EDIT FIELDS AS NECESSARY]

Employer Information

*Organization Name: ______________________________

(e.g., name of school district, name of government agency)

Department Name: ________________________________(e.g., school name, government department)

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

First: Last:

___________________________ __________________________

Supervisor’s Business Address

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ __________________

E-mail: Verify E-mail:

_________________ ________________

Alternate E-mail Address: Verify Alt. E-mail:

_ ___

Fax: TTY:

_______ _

Human Resource Manager

First: Last:

___________________________ __________________________

Human Resource Manager’s Business Address:

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ __________________

E-mail: Verify E-mail:

_________________ ________________

Alternate E-mail Address: Verify Alt. E-mail:

_ ___

Fax: TTY:

_______ _

Name of person completing this form

_______________________________

Employment Verification Page 2

Please review the information below.

If you AGREE with all of the participant’s responses, click the Submit button at the bottom of the page. If you DISAGREE with the participant's response to a particular question, please check the “Disagree” box beside the question. Once you have selected all the questions for which you disagree with the response, click the Submit” button at the bottom of the page. You will have an opportunity to describe the reason for your disagreement on the following page. An Employment Dispute Report will be provided to the participant and he or she will have the opportunity to review your changes, revise responses as needed and resubmit the record for verification.

Employee Name: [PRE-FILLED]

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

Participant Answer: