Grantee Scholar Record

Personnel Development Program

Data Collection System

Scholar Record

(Completed by Grantee)

OMB Control Number: 1820-0686

Expiration:

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.  The valid OMB control number for this information collection is 1820-0686.  Public reporting burden for this collection of information is estimated to average 20 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 requirements, 34 CFR Part 304 Volume 70 No. 57 March 25, 2005, and regulations, 34 CFR Part 304 Vol. 71 No. 107 June 5, 2006, printed in the Federal Register.  If you have any comments concerning the accuracy of the time estimate, suggestions for improving this individual collection, or if you have comments or concerns regarding the status of your individual form, application or survey, please contact Office of Special Education and Rehabilitative Services, U.S. Department of Education, 550 12^th St. SW, Washington, D.C. 20202 or email [email protected] directly.

Rules of Behavior for Department of Education-Sponsored Website

The Office of Special Education Program’s Personnel Development Program (PDP) Data Collection System (PDPDCS) is an online data collection system designed to facilitate administration of the PDP Program. 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 ensure 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. 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. Disclosures may also be made to qualified researchers under Privacy Act safeguards. 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 PDPDCS 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 PDPDCS 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 digitally sign or upload a scanned 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 form for Pre-Scholarship Agreements. The grantee representative and scholar must complete and digitally sign the document or upload a signed and scanned copy. 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) the scholar held when he/she entered this OSEP grant-supported training (check all that apply):

• High school diploma or equivalency [If only degree, go to Question 4]

• Associate’s Degree

• Bachelor's Degree

• Master's Degree

• Educational Specialist

• Doctoral Degree

• Postdoctoral Degree

• State or Professional Credential/Certificate

• State-issued Endorsement

*2a. 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(s) and children with disabilities categories under 2b and 2c)

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

2b. If the scholar was granted a degree/certificate/endorsement prior to entry into this OSEP grant-supported training, select the training area that best describes the PRIMARY focus of the degree/certificate/endorsement. If appropriate, select up to three additional OTHER FOCUS AREAS to provide more detailed information about the scholar's prior training.

Training Area	Primary Focus	Other Focus Areas
Early Intervention/Early Childhood Special Education		
Special Education (School-Age)	q	q
Deaf Education	q	q
Educational Interpreter	q	q
Teaching Students with Visual Impairments	q	q
Orientation & Mobility	q	q
Speech Language Pathology	q	q
Audiology	q	q
School Psychology	q	q
Applied Behavior Analysis (ABA)	q	q
School Counseling	q	q
Social Work	q	q
Rehabilitation Counseling	q	q
Adapted Physical Education	q	q
Occupational Therapy	q	q
Physical Therapy	q	q
Administration	q	q
Combined Studies: General Education and Special Education	q	q
Assistive Technology	q	q
Bilingual Special Education/ESL/TESOL	q	q
Secondary Transition	q	q
Other (Text Box) Instructions: If the categories above are not appropriate for the focus of your grant, please provide a brief description of the scholar’s training focus below.	q	q

2c. If applicable, indicate the children with disabilities category(s) that the scholar received training to support prior to entry into this OSEP grant-supported training. Select all that apply.

	Autism
	Deaf-blindness
	Deafness
	Developmental Delay
	Emotional Disturbance
	Hearing Impairment
	Intellectual Disabilities
	If yes, does this include children with significant cognitive impairment?  Yes  No
	Multiple Disabilities
	If yes, does this include children with significant cognitive impairment?  Yes  No
	Orthopedic Impairment
	Other Health Impairment
	Specific Learning Disability
	Speech-Language Impairment
	Traumatic Brain Injury
	Visual Impairment, including Blindness
	No Specific CWD Category Training Focus

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:

• Early Interventionist or Early Childhood Special Educator

• Special Education Teacher (School-Age)

• Deaf Educator

• Interpreter for the Deaf

• Teacher of the Visually Impaired

• Orientation & Mobility Specialist

• Speech Language Pathologist

• Audiologist

• School Psychologist

• Applied Behavior Analyst

• School Counselor

• Social Worker

• Rehabilitation Counselor

• Adapted Physical Educator

• Occupational Therapist

• Physical Therapist

• Administrator/Coordinator/Supervisor (including the capacity of a principal)

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

• Other

• General Education and Special Education Teacher (combined)

• Assistive Technology Specialist

• Bilingual/ESL/TESOL Special Education Teacher

• Secondary Transition Specialist

• Instructional Specialist

• Paraprofessional

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. Please note, this date may be different from the date the scholar began receiving funding through the grant.

*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

• Course completion only; no degree(s), certificate(s), or endorsement(s) will be awarded when the scholar completes the OSEP grant-supported training

*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 the training area that best describes the PRIMARY focus of the degree/certificate/endorsement that this scholar received from this OSEP grant-supported training. If appropriate, select up to three additional OTHER FOCUS AREAS to provide more detailed information about the scholar's focus of training.

Training Area	Primary Focus	Other Focus Areas
Early Intervention/Early Childhood Special Education		
Special Education (School-Age)	q	q
Deaf Education	q	q
Educational Interpreter	q	q
Teaching Students with Visual Impairments	q	q
Orientation & Mobility	q	q
Speech Language Pathology	q	q
Audiology	q	q
School Psychology	q	q
Applied Behavior Analysis (ABA)	q	q
School Counseling	q	q
Social Work	q	q
Rehabilitation Counseling	q	q
Adapted Physical Education	q	q
Occupational Therapy	q	q
Physical Therapy	q	q
Administration	q	q
Combined Studies: General Education and Special Education	q	q
Assistive Technology	q	q
Bilingual Special Education/ESL/TESOL	q	q
Secondary Transition	q	q
Other (Text Box) Instructions: If the categories above are not appropriate for the focus of your grant, please provide a brief description of the scholar’s training focus below.	q	q

4b. If applicable, indicate the children with disabilities category(s) that the scholar received training to support as part of this OSEP grant-supported training. Select all that apply.

	Autism
	Deaf-blindness
	Deafness
	Developmental Delay
	Emotional Disturbance
	Hearing Impairment
	Intellectual Disabilities
	If yes, does this include children with significant cognitive impairment?  Yes  No
	Multiple Disabilities
	If yes, does this include children with significant cognitive impairment?  Yes  No
	Orthopedic Impairment
	Other Health Impairment
	Specific Learning Disability
	Speech-Language Impairment
	Traumatic Brain Injury
	Visual Impairment, including Blindness
	No Specific CWD Training Focus

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

Please enter information about the scholar’s employment during each budget period that

the scholar was enrolled in the program, regardless whether funding was received

that year. 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 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. [Question revealed for each budget period if yes] Average number of hours per week of employment:

_______ (Round to the nearest hour)

3. [Question revealed for each budget period if yes] Is this position:

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

• Same position held in previous budget period

• Different or new position

4. [Question revealed for each budget period if yes] Choose one type of employment that best describes this scholar’s position:

• Early Interventionist or Early Childhood Special Educator

• Special Education Teacher (School-Age)

• Deaf Educator

• Interpreter for the Deaf

• Teacher of the Visually Impaired

• Orientation & Mobility Specialist

• Speech Language Pathologist

• Audiologist

• School Psychologist

• Applied Behavior Analyst

• School Counselor

• Social Worker

• Rehabilitation Counselor

• Adapted Physical Educator

• Occupational Therapist

• Physical Therapist

• Administrator/Coordinator/Supervisor (including the capacity of a principal)

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

• Other

• General Education and Special Education Teacher (combined)

• Assistive Technology Specialist

• Bilingual/ESL/TESOL Special Education Teacher

• Secondary Transition Specialist

• Instructional Specialist

• Paraprofessional

 I. Scholar Status

Please indicate the appropriate program status of the scholar below. You must complete all sub questions 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. (Go to question 2)

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

*Please specify 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 DCS 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 24 months.

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 the training area that best describes the PRIMARY focus of the degree/certificate/endorsement that this scholar received from this OSEP grant-supported training. If appropriate, select up to three additional OTHER FOCUS AREAS to provide more detailed information about the scholar's focus of training.

Training Area	Primary Focus	Other Focus Areas
Early Intervention/Early Childhood Special Education		
Special Education (School-Age)	q	q
Deaf Education	q	q
Educational Interpreter	q	q
Teaching Students with Visual Impairments	q	q
Orientation & Mobility	q	q
Speech Language Pathology	q	q
Audiology	q	q
School Psychology	q	q
Applied Behavior Analysis (ABA)	q	q
School Counseling	q	q
Social Work	q	q
Rehabilitation Counseling	q	q
Adapted Physical Education	q	q
Occupational Therapy	q	q
Physical Therapy	q	q
Administration	q	q
Combined Studies: General Education and Special Education	q	q
Assistive Technology	q	q
Bilingual Special Education/ESL/TESOL	q	q
Secondary Transition	q	q
Other (Text Box) Instructions: If the categories above are not appropriate for the focus of your grant, please provide a brief description of the scholar’s training focus below.	q	q

2b. If applicable, indicate the children with disabilities category(s) that the scholar received training to support as part of this OSEP grant-supported training. Select all that apply.

	Autism
	Deaf-blindness
	Deafness
	Developmental Delay
	Emotional Disturbance
	Hearing Impairment
	Intellectual Disabilities
	If yes, does this include children with significant cognitive impairment?  Yes  No
	Multiple Disabilities
	If yes, does this include children with significant cognitive impairment?  Yes  No
	Orthopedic Impairment
	Other Health Impairment
	Specific Learning Disability
	Speech-Language Impairment
	Traumatic Brain Injury
	Visual Impairment, including Blindness
	No Specific CWD Category Training Focus

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 (select all that apply).

• Grantee specific measure [Options shown below if grantee specific test is selected]

  • 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 for licensure or certification

• PRAXIS II

• State specific test for licensure or certification

• Other Test (specify): ____________

5a-e. [Question revealed for each selected exam or measure] Did the scholar pass this exam or measure?

• Yes

• No

• Don’t know

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

K. Service Obligation Information and Exit Certification

Please digitally signed or upload a scanned 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 form for the Exit Certification form. The grantee representative and scholar must complete and digitally sign or upload a scanned copy of the signed 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 PDPDCS 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.

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