Scholar Training and Employment Record

Personnel Development Program

Data Collection System

Scholar Training and Employment Record

(Completed by Scholar)

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 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  The obligation to respond to this collection is 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.

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 from and about you is requirements, including service obligation fulfillment or repayment of your financial obligation.information is voluntary, but you must provide the requested information, including your 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 educational is voluntary and that giving us your student Office of Special Education (OSEP) Personnel Development Program (PDP) under this authority in order to accurately track your records and to differentiate your financial obligation from other scholars who may have the same name as you. You are advised that your participation in the ,personally identifiable information (PII) including pertinent to the OSEP scholarship grant received whether provided by the scholar, grantee, or other entity,scholar educational information We request your part D of the Individuals with Disabilities Education Act, as amended by the Individuals with Disabilities Education Improvement Act of 2004.

The information in your 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 . 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. particular records

Rules of Behavior for Department of Education-Sponsored Website

The Personnel Development Program (PDP) Data Collection System (PDPDCS) is an online data collection system designed to facilitate administration of the Personnel Development Program, in the Office of Special Education Programs at the US Department of Education. This system collects training, 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 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 Government Performance and Results Act of 1993, section 4.

Scholars using this system agree to:

• Maintain requested contact and employment information; and

• Maintain their PDPDCS accounts by:

  • Protecting account login names and passwords;

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

  • Using the PDPDCS only to access their own information.

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

□ I agree to the terms.

The information contained in this record was added by the Institution of Higher Education (IHE) at which you received your funded training. You are required to provide the PDPDCS with up-to-date contact information. To edit the information below, click on the Edit My Information link. To change your password, click on the Change My Password link. For security reasons you must contact PDPDCS at 1-800-285-6276 or [email protected] to change your name or Social Security Number.

You will be logged out of the system after 30 minutes of inactivity. A warning message will appear after 25 minutes of inactivity.

[ALL DATA IN SECTIONS A THROUGH C WILL BE PRE-FILLED BASED ON GRANTEE RESPONSES IN THE GRANTEE SCHOLAR RECORD. SCHOLARS WILL ONLY NEED TO UPDATE INFORMATION THAT IS INCORRECT OR HAS CHANGED.]

A. Identifying Information
*First Name			Middle Name		*Last Name
Maiden Name, if applicable:
*Social Security Number (last 4)
*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

B. Contact Information
Permanent Address
*Address
Address Line 2:
*City		*State		*Zip Code
*Phone		Cell Phone
Secondary Address
Address
Address Line 2:
City		State		Zip Code
Other Phone		Fax

C. Alternate Contact Information

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 six months.

□ I have reviewed the information in Sections A, B, and C, and it is still current.

D. Training Program

Please verify that the information provided by your Institution of Higher Education (IHE) is correct. If any of the items do not match your records, please contact your IHE. We also encourage you to contact PDPDCS at 1-800-285-6276 or [email protected] so that a ticket can be created concerning this matter. Your IHE must contact PDPDCS to edit your record. [ALL DATA IN SECTION D, EXCEPT THE LAST ITEM “VERIFY SERVICE OBLIGATION DETAILS” WILL BE PRE-FILLED BASED ON GRANTEE RESPONSES IN THE SCHOLAR RECORD.]

IHE

Project Title

Grant Number

Exit/Completion Date

Date of Completion of One Academic Year

Date Record Created by IHE

Date of Last IHE Update

EDUCATION INFORMATION

1. Degree(s) or certificate(s) or endorsement(s) you held when you entered this grant-supported training:

[Display of the item(s) selected by the grantee.]

2. Degree(s) or certificate(s) or endorsement(s) you received as a result of completing this grant-supported training:

[Display of the item(s) selected by the grantee.]

TRAINING AREAS

1. Training area that best describes the focus of your degree(s):

[Display of the item(s) selected by the grantee.]

2. Additional training areas that describe the focus of your degree(s):

[Display of the item(s) selected by the grantee.]

VERIFY SERVICE OBLIGATION DETAILS

○ I certify that the service obligation details entered by my IHE are correct.

○ I disagree with the service obligation details entered by my IHE and will contact the project director and the PDPDCS Help Desk at 1-800-285-6276 or [email protected].

[ONLY DISPLAY FOR SCHOLARS WHO EXITED THE PROGRAM PRIOR TO COMPLETION]

PROGRAM COMPLETION

Have you completed/graduated from this program (the program from which you had previously received funding from your IHE through an OSEP grant)?

• Yes

• No

[ONLY DISPLAY IF RESPONSE TO QUESTION ABOVE IS YES]

Please provide the date of completion/graduation:

E. Service Obligation Status

The service obligation information below is current as of your IHE’s last update on [INSERT DATE]. These totals are expected to increase if you are currently receiving funding or expect to receive more funding prior to the completion of your program; therefore, this may not be your final service obligation in months and dollars. When you complete or exit the program, your IHE will update your record with your final service obligation details. If you have questions regarding this information, please contact your IHE.

[ALL FIELDS IN TABLE BELOW ARE PRE-FILLED]

Accumulated Academic Years of Funding:		Total Funding Received:
Total Service Obligation Owed:		Total Grace Period Provided per Program Requirements/Regulations:
Program Completion Status:		Service Obligation Status:
Total Service Obligation Fulfilled to Date (if applicable):		Remaining Service Obligation:
Total Time Remaining for Completion of Service Obligation:		Date by Which Service Obligation Must be Completed:

Click here to view a copy of your Pre-Scholarship Agreement.

 F. Eligible Employment

Eligible employment must: 1) fulfill at least one of the requirements listed in Sec. F(e) of the 2005 Program Requirements or §304.30(e) of the 2006 Program Regulations; 2) provide compensation; and 3) if serving children, the children served must fall under the definition of eligible children as described in IDEA 2004 Sec. 602(3). Only eligible employment records can be submitted for employer verification. You will receive an error message if the position is not eligible.

Once you have submitted an employment record, it will be sent by PDPDCS to your employer for verification. Once it has been verified by your employer, credit will be applied to your total service obligation fulfilled to date. Your employer will have 30 days from the date of submission to verify or dispute the information in the record. For more information on disputed records, click on the "View All Employment Records" link.

Once your employment record has been verified by your employer, you will be notified by PDPDCS. Credit will be applied to your total service obligation fulfilled to date.

To update your current employment record prior to submitting it for verification, click on the "Update Current Employment" link or on the name of your current employer. You cannot update your current employment record during your employer’s 30–day verification period until your employer verifies or disputes the record or the 30-day verification window expires. Note that past employment records cannot be edited once submitted and verified.

Note that if your current full-time position becomes part-time, you must add an end date to the current full-time record and create a new record for the part-time position.

REPORTING REQUIREMENTS

As a scholar, you are required to update PDPDCS with your contact and employment information every 6 months. You will receive reminder emails and phone calls from PDPDCS reminding you to add an employment record or update your current employment record.

If you are within the grace period (additional period of time) or have no changes to your employment, you must click the check box below. Otherwise you must enter employment information.

 □  I do not have changes to my employment at this time.

G. Deferrals and Exception
	According to the 2005 Program Requirements (Sec.G.) and 2006 Program Regulations (§ 304.31) available on the PDPDCS Web site (http://pdp.ed.gov/OSEP/Home/Regulation), you may apply for an "exception or deferral to performance or repayment under the agreement" you signed with your university in return for funding. Requests are reviewed by the Data Collection Center and the Office of Special Education Programs. Scholars are required to submit supporting documentation with their deferral or exception request. Evidence to support a deferral request must include official documentation from the appropriate entity, such as an Institution of Higher Education (IHE), the armed services, or Peace Corps. Evidence to support an exception request must also contain official documentation, such as a death certificate or a statement from a medical professional, as appropriate. Please refer to frequently asked question #26, available on the PDPDCS Web site (http://pdp.ed.gov/OSEP/Home/faq) for additional information. You can upload an electronic version of the documentation below or you may mail or fax the documentation to the PDPDCS Helpdesk at 1600 Research Blvd, RA 2173, Rockville, MD 20850 or 888-252-6960. REASON FOR EXCEPTION I am unable to continue a course of study, perform the service obligation, or repay all or part of the funding received because of a permanent disability.   REASON FOR DEFERRAL I am engaging in a full-time course of study at an institution of higher education. REASON FOR DEFERRAL I am serving on active duty as a member of the armed services of the United States. I am serving as a volunteer in the Peace Corps or Domestic Volunteer Service.   SUPPORTING DOCUMENTATION Please upload the appropriate documentation to support your exception or deferral request. Depending on the file size of the attachment, the upload process may take up several minutes. Acceptable file types include .doc, .docx, and .pdf. Please note that file names or titles cannot have spaces. You may use underscores: for example, John_Doe_deferral_request.doc. File to upload:

Employment Record

Employment Information

The questions relating to your employment affect your service obligation fulfillment status. You must answer every question to the best of your ability. Providing information that you know to be false may be punishable by law (False Claims Act, 31 USC § 3729).

Employer Information

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

Please provide the name of a supervisor 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:

_________________ ___________________

Email: Verify Email:

_________________ ________________

Alternative Email: Verify Alternative Email:

_________________ ___________________

Fax: TTY:

_____________________ _____________________

Human Resource Manager

Please provide the name of a human resources manager 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:

_________________ ___________________

Email: Verify Email:

_________________ ________________

Alternative Email: Verify Alternative Email:

_________________ ___________________

Fax: TTY:

_____________________ _____________________

Organization Type
What type of organization is this? * Public School (including Charters) Private School Federal Government Agency State Government Agency Local Government Agency College/University	Early Intervention/Early Childhood Program For-Profit or Commercial Organization Non-Profit Organization Hospital, medical offices, or clinics Other, Please Specify: _____________

Employment Information

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

Question #8 does not affect your service obligation fulfillment status. This question is for measuring program performance at the Office of Special Education Programs.

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

1. *Is this your current employment?

• Yes

• No

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

Please note: According to program regulations, scholars may begin work in eligible employment following the completion of one academic year of training. Therefore, the DCS only allows for start dates of an employment position after the completion of one academic year of training (mm/dd/yyyy).

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

• Early Interventionist or Early Childhood Special Educator

• Special Education Teacher (general)

• 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)

• General Education and Special Education Teacher (combined)

• Assistive Technology Specialist

• Bilingual/ESL/TESOL Special Education Teacher

• Secondary Transition Specialist

• Instructional Specialist

• Paraprofessional

• Other, please specify: (text box)

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

3a. Full Time (As defined by your Employer and must be 30 hours or more per week)

• This is a summer position

• This position has summers off

• This is a year round position

3b. Part Time

• If this employment is part-time, on average, how many hours do you work per week at this job? ______

4. Is this position a substitute teaching position?

• No

• Yes

5. Select the area that best describes the PRIMARY focus of this employment position. If appropriate, select up to three additional OTHER FOCUS AREAS to provide more detailed information about this employment position.

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

6. If applicable, indicate the children with disabilities category(s) that this employment position supports. 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

Please answer the questions below that best describe the work you do in this position. Eligible employment must: 1) fulfill at least one of the requirements listed in section F(e) of the 2005 Requirements or section 304.30(e) of the 2006 Regulations; 2) provide compensation; and 3) if serving children, the children must fall under the definition of eligible children as described in IDEA 2004, section 602(3).

[ONLY DISPLAY ITEMS 7A AND 7B IF SCHOLAR SELECTS ANY RESPONSE OTHER THAN ADMINISTRATOR/COORDINATOR/SUPERVISOR, HIGHER EDUCATION OR OTHER.

DISPLAY 7C IF SCHOLAR SELECTS ADMINISTRATOR/COORDINATOR/SUPERVISOR, HIGHER EDUCATION OR OTHER FOR ITEM 2]

7a. *Describe the percentage of time spent teaching or serving special education students in this position.

• 50% or less

• At least 51%

7b. *Describe the percentage of special education students taught or served in this position.

• 50% or less

• At least 51%

7c. *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.

• 50% or less

• At least 51%

8.  *Are you certified/licensed for this position? If yes, please select all certifications that apply Certified/licensed for purposes of this data collection means that you meet the state requirements (if there are requirements in your state) for certification/licensure for this position.

• Certified/licensed

• Not certified/Not licensed

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

• Not applicable to this type of employment position

[DISPLAY ITEMS IF SCHOLAR SELECTS “CERTIFIED/LICENSED”]

• Early Intervention (EI) State License/Certification; Early Childhood Special Education (ECSE) State License/Certification

• Special Education Teacher License

• Deaf Education State Teacher License/Certification

• Interpreter State License/Certification

• Blind or Visually Impaired State Teacher License/Certification

• Orientation & Mobility (O&M) State License/Certification

• Speech Language Pathologist (SLP) State License/Certification

• Audiology State License/Certification

• School Psychology State License/Certification; Nationally Certified School Psychologist (NCSP)

• Board Certificated Behavior Analyst (BCBA) National Certification

• School Counseling State License/Certification

• Social Work State License/Certification

• Rehabilitation Counseling State License/Certification

• Adapted Physical Education State Teacher License/Certification

• Occupational Therapy (OT) State License/Certification

• Physical Therapy (PT) State License/Certification

• Other

9. * Please select the Supervisor or HR Manager to whom you wish to send this information for verification (Select at least one).

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.

[ONLY COMPLETED BY SCHOLARS WHO ARE SELF-EMPLOYED]

Personnel Development Program (PDP) Data Collection System (DCS)

Scholar Self-Employment Verification Instructions

Please follow these instructions to receive service obligation credit for a self-employment position.

Only eligible employment records can be submitted for employer verification through the Data Collection System (DCS). Eligible employment must:

1. Fulfill at least one of the requirements listed in Sec.F(e) of the 2005 Requirements or

§304.30(e) of the 2006 Program Regulations, depending on year of grant award;

2) Provide compensation; and,

3) If serving children, the children served must fall under the definition of eligible

children as described in IDEA 2004 Sec. 602(3). You will receive an error message if

the employment is not eligible.

All the information entered into the DCS is subject to the False Claims Act, 31 USC § 3729. Anyone who purposely submits false or misleading information, 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 the false statement.

Scholars are eligible to enter employment after they have completed one academic year of the program. See FAQ #11, “What is the minimum amount of academic training a scholar must complete before he or she may start to fulfill the service obligation through employment?”

(https://pdp.ed.gov/OSEP/Home/faq2005#8 or https://pdp.ed.gov/OSEP/Scholar/faq2006#8)

Scholars in a self-employed position are required to submit supporting documentation to verify their status of self-employment along with the Self-Employment Notary Request Form.

List of required supporting documentation:

• Active State Registered Business License (Required. If not required by state, similar documentation must be submitted.)

• Signed copy of filed business tax return form (Required. First two pages only, without the additional attachments), year(s) must align with employment dates.

List of optional supporting documentation: *Note: Optional documents cannot be used in place

of the two required documents listed above.

• Certified Financial Statement from CPA.

• Letter of Verification of Business from CPA/Attorney validating current self-employment.

• Certificate of Good Standing obtained from the State Corporation Commission.

To enter an employment record for a self-employed position, follow the instructions below:

Employment Record Form Page One: EMPLOYER INFORMATION

1. Log into the DCS at https://pdp.ed.gov/OSEP/logon/Login

2. On the "Scholar Main Menu," scroll down to Section F. “Eligible Employment,” and select the hyperlink "Add Employment Record." This link will direct you to the Employment Record Form.

Note: Required items on the form are marked with an asterisk*.

3. Organization Name: Enter the legal name of your business as it appears on your tax return(s).

4. Organization Address: Enter the mailing address and phone number for your business.

5. Supervisor: Enter your name, business contact information, and [email protected] as the Supervisor email address (see Figure A below).

Figure A. Employment Record Form Supervisor Section

6. Human Resource Manager: Leave this section blank.

7. Organization Type: Select the appropriate answer.

8. Select “Next.”

Employment Record Form Page Two: EMPLOYMENT INFORMATION

9. Questions #1 – #8 (Questions #6 - #7, if applicable): You must answer every question to the best of your ability. Question #8 does not affect your service obligation fulfillment status. This question is for measuring performance of the programs at the Office of Special Education Programs.

10. Question #9: Select the designated Supervisor as created in Step 5 of the instructions as the Employer to submit the Employment Record for verification.

11. Select the box, “I certify that all of the information I have provided is true and correct to the best of my knowledge.”

12. Select “Save and Submit.” Once the employment record is submitted, an automated notification e-mail is sent to the Supervisor email address as entered in Step 5 of these instructions.

• The employment records may be saved and edited at a later date by selecting “Save for Later” at the bottom of the form. To submit Employment Record(s), scholars must select “Save and Submit” at the bottom of the form.

• Note that past employment records cannot be edited once submitted. Current employment records can be edited; however, scholars cannot edit submitted Employment Record(s) during the 30-day verification period or until the record has been verified or disputed.

After you Save and Submit the employment record:

13. Within 24 hours, PDPDCS will forward to you the completed Employment Record Form along with a Self-Employment Notary Request Form by email, from [email protected].

14. Complete and sign the Self-Employment Notary Request Form in the presence of a notary.

15. Send the following documents to PDPDCS: the completed Employment Record Form, the notarized Self-Employment Notary Request Form, and the supporting documents listed below:

• Active State Registered Business License (Required. If not required by state, similar documentation must be submitted).

• Signed copy of filed business tax return form (Required. First two pages only, without the additional attachments), year(s) must align with employment dates.

Mail	Email	Fax
Westat Attn: Self-Employment Verification 1700 Research Blvd. RB 2268 Rockville, MD 20850	[email protected]	1-888-252-6960 Attn: Self-Employment Verification, RB 2268

16. Upon receipt of all required documents, PDPDCS will review the documentation. If PDPDCS approves the documentation, PDPDCS will verify the employment record in the DCS. Once the record has been verified, credit will be applied to your total service obligation fulfilled to date.

17. If PDPDCS disagrees or finds the information provided to be incomplete, PDPDCS will dispute the employment record through the DCS.

• If disputed, you will receive an Employment Dispute Report by email from [email protected], explaining why the record was not verified.

• You will then be allowed to edit and resubmit the record.

• Credit will not be applied to your total service obligation fulfilled to date, until the dispute is resolved, and the employment record has been verified.

If you have any questions, feel free to contact the PDPDCS at 800-285-6276 or by e-mail at [email protected]. Support is available Monday-Friday, from 8 a.m. to 8 p.m. (ET).

Personnel Development Program (PDP) Data Collection System (DCS)

Self-Employment Notary Request

Employment Record (this section to be completed by PDPDCS):

Organization Name: Record ID:

Start Date: End Date (if applicable): Last Updated:

Complete the section below in the presence of a Notary:

I (Scholar’s Full Name) certify that all the information I have provided within the Personnel Development Program Data Collection System Employment Form for the record referenced above 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).

Scholar Name (Print) Scholar Signature Date

Notary:

County/City of

Commonwealth/State of

The foregoing instrument was acknowledged before me this day of

20 by

(Name of Person Seeking Acknowledgment)

My Commission Expires:

Notary Public

Commission Number:

Forward the notarized form and two required documents that demonstrate self-employment to:

Mail	Email	Fax
Westat Attn: Self-Employment Verification 1700 Research Blvd. RB 2268 Rockville, MD 20850	[email protected]	1-888-252-6960 Attn: Self-Employment Verification, RB 2268