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

OMB Control Number: 1810-0698

Expiration: XX/XX/XXXX

Indian Education Professional Development Program

Data Collection System

Participant Training Information and Employment Reporting Form

OMB Control Number: 1810-0698

Expiration: XX/XX/2022

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. The valid OMB control number for this collection is 1810-0698. 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 Title VI of the Elementary and Secondary Education Act, 20 USC §7442, and its corresponding regulations at 34 CFR Part 263. 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 Angela Hernandez, Education Program Specialist, Office of Indian Education, U.S. Department of Education, 400 Maryland Ave SW, Room 3W248, Washington, DC 20202 or email Angela.Hernandez @ed.gov..

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 you is section 7122 of the Elementary and Secondary Education Act of 1965, as amended. We request your information pertinent to the Indian Education Professional Development Program (PDP) grant received whether provided by you the participant, the grantee providing you funding, or other entity, including social security number and other personally identifiable information (PII), under this authority in order to accurately track your records and to differentiate your financial obligation from other participants who may have the same name. You are advised that your participation in the PDP is voluntary, but you must provide the requested information, including your PII, in order to participate in the PDP. The information will be used to ensure that recipients of scholarships provided with funds meet specific statutory and regulatory requirements, including service obligation fulfillment or repayment of financial obligation.

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 your identity and location and to the Department of Treasury, collection agencies, and your employers 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.

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 about participants to verify the fulfillment of their payback agreements. 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 participant access to the PDPDCS.

Participants 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, email address, employment status and employer information; and

• Using the PDPDCS only to access their own information;

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

□ I agree to the terms.

Participant Training Information and

Employment Reporting Form

Instructions

Participant Main Menu

The information contained in this record was added by the grantee from which you received your funded training. You are required to provide up-to-date contact information. To edit the information below, click on the "Edit My Information" link. For security reasons you must contact PDPDCS at 1-888-884-7110 or [email protected] to change your name and 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 PARTICIPANT RECORD FORM. PARTICIPANTS WILL ONLY NEED TO UPDATE INFORMATION THAT IS INCORRECT OR HAS CHANGED PARTICIPANTS WILL NOT BE ABLE TO UPDATE NAME AND SOCIAL SECURITY NUMBER FIELDS.]

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
(Please do not use a university email address.)
*Verify Primary E-mail Address
Alternative E-mail Address
Verify Alternative E-mail Address

B. Contact Information
Primary Address
*Address
*City		*State				*Zip Code
*Home Phone		Cell Phone
Secondary Address
Address
City		State				Zip Code
Other Phone

C. Alternate Contact Information

First Name

Last Name

E-mail Address

Verify Primary E-mail Address

Address

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 and Service Payback Details

Please certify that the information provided by your grantee is correct. If any of the items do not match your records, please contact your grant project director. Your grant project director will have to contact PDPDCS to edit your record. We also encourage you to contact PDPDCS at 1-888-884-7110 or [email protected] so that a Help Desk ticket can be created concerning this matter.

[ALL DATA IN SECTION D, EXCEPT THE LAST ITEM “VERIFY SERVICE PAYBACK DETAILS” WILL BE PRE-FILLED BASED ON IHE RESPONSES IN THE PARTICIPANT RECORD FORM.]

Training Program: [PRE-FILLED]

IHE

Project Title

Grant Number

Exit/Completion Date

Date Record Created by Grantee

Date of Last Grantee Update

EDUCATION INFORMATION

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 from the list below:

 □  High school diploma or equivalency
 □  Associate’s Degree
 □  Bachelor's Degree
 □  Master's Degree
 □  Educational Specialist
 □  Doctoral Degree
 □  Postdoctoral Degree
 □  State, Tribal or Professional Credential/Certificate
 □ State-issued Endorsement
 □  Grantee-issued Endorsement]

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 IHE from the list below:

 □  Associate’s Degree
 □  Bachelor's Degree
 □  Master's Degree
 □  Educational Specialist
 □  Doctoral Degree
 □  Postdoctoral Degree
 □  State, Tribal or Professional Credential/Certificate
 □ State-issued Endorsement
 □  Grantee-issued Endorsement]

PROGRAM INFORMATION

Major field of study associated with your degree earned:

[Display of the item(s) selected by the grantee from the list below:]

General Area of Education

 □  Administration
 □  Elementary Education

 □  Secondary Education

 □  Special Education

Subject Area

 □  Not Applicable

 □  Arts and Music

 □  Bilingual or English as a Second Language

 □  Early Childhood Education

 □  English or Language Arts

 □  Language Education (Native/Heritage/World Language)

 □  Health or Physical Education

 □  Mathematics or Computer Science

 □  Natural Sciences

 □  Social Sciences

 □  Career or Technical Education

 □  Other (please specify) __________]

Area of certification you attained after project training:

[Display of the item(s) selected by the grantee from the list below:

General Area of Education

 □  Administration
 □  Elementary Education

 □  Secondary Education

 □  Special Education

Subject Area

 □  Not Applicable

 □  Arts and Music

 □  Bilingual or English as a Second Language

 □  Early Childhood Education

 □  English or Language Arts

 □  Language Education (Native/Heritage/World Language)

 □  Health or Physical Education

 □  Mathematics or Computer Science

 □  Natural Sciences

 □  Social Sciences

 □  Career or Technical Education

 □  Other (please specify) __________

TRAINING PROGRAM EXIT/COMPLETION INFORMATION

[Display of the item selected by the grantee from the list below:

○ I am still enrolled in my program of study.

○ I am taking a leave of absence. (A leave of absence must be pre-approved by your project director, cannot exceed 1 year, and does not extend the availability of funds when the project ends)

○ I am on active military deployment.

○ I have completed my program of study.

○ I have exited the training program without completing my program of study.]

SERVICE PAYBACK INFORMATION:

1. Total number of months you were enrolled in training as of <INSERT DATE>:__________

2. Total funding amount received as of <INSERT DATE>:

Type of Expense	Cost ($)
Tuition, Books, and Fees
Stipend (i.e., costs related to room, personal living expenses, and/or board)
Dependent Allowance
Supplies
Technology (i.e., computers, and related items)
Required Program Travel
Miscellaneous (explain)
TOTAL	$[Sum of above]

□ Amounts listed above are final. This box will be checked if the cumulative totals above represent the final amounts for this participant. This box will only be checked if the participant has completed the program or exited the program prior to completion.

VERIFY PAYBACK DETAILS

○ I certify that the service payback details entered by my grant project director are correct.

○ I disagree with the service payback details entered by my grant project director and will contact the project director and the PDPDCS Help Desk at 1-888-884-7110 or paybackobligations.ed.gov.

E. Service Payback Status

The service obligation information below is current as of your grant project director’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 or if you will receive funding during induction services; therefore this may not be your final service payback in months and dollars. When you complete or exit the program, your grant project director will update your record with your final service payback details. If you have questions regarding this information, please contact your grant project director. For definitions of the terms below, please click on any of the underlined links. [ALL FIELDS IN TABLE BELOW ARE PRE-FILLED]

Total Months of Funding:		Total Funding Received:
Total Service Payback Owed:		Total Grace Period Provided per Program Regulations:	12 months
Program Completion Status:		Total Time Remaining in Grace Period:
Total Service Payback Fulfilled to Date (if applicable):		Remaining Service Payback:
Current Service Payback Status:		Date Service Payback Must Be Completed:

Click here to view a copy of your service payback agreement.

Notice of Intent [MUST BE COMPLETED WITHIN 30 DAYS OF PROGRAM COMPLETION]

1. *1. Please select one option below to indicate your intent to complete a work-related or cash payback

2.  ○  Work-related payback

I understand by selecting this option I agree to report my employment information in Section F every 6 months until my service payback obligation has been fulfilled.

3.  ○  Cash payback

   1. I understand by selecting this option I will be referred to the U.S. Department of Education’s, Accounts Receivable and Banking Management Division (ARBMD) to establish a repayment plan.

○  I am continuing in a degree program as a full-time student and wish to request an educational deferment to delay service or fiscal payback for funds I received from this grant.

2. I understand by selecting this option I will need to provide the information in Section G.

 F. Qualifying Employment

Eligible employment must 1) be related to the training received; and 2) benefit Indian people. Only eligible employment can be submitted for employer verification. You will receive an error message if the position is not eligible and will need to contact the PDPDCS Help Desk at 1-888-884-7110 or [email protected] for assistance.

Once you enter employment information into PDPDCS an employment record will be created and the record will be sent to your employer for verification. 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.

Note that past employment records cannot be edited once submitted, but current employment records can be edited. You will receive credit for current employment through the date the record was last updated. 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. To update your current employment record, click on the "Update Current Employment" link or on the name of your current employer. Current employment records should be sent to your employer for verification once every 6 months.

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.

Employment Record Form

Employment Information

The questions relating to your employment affect your payback 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.

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 work e-mail address. You will be asked on the next page to indicate which contact 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.

*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:

_________________ ___________________

Organization Web site address (Ensure the Web site has the prefix "http://".):

__________________________________

Supervisor

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:

_________________ ___________________

*Email: *Verify Email:

_________________ ________________

Alternate Email Address: Verify Alt. Email:

_________________ ___________________

Fax:

_____________________

Human Resource Manager

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 Business Address: 

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ ___________________

*Email: *Verify Email:

_________________ ________________

Alternate Email Address: Verify Alt. Email:

_________________ ___________________

Fax:

_____________________

Organization Type
*1. What type of organization is this? Public school Charter school Local Education Agency (LEA) BIE-funded school

Employment Information

Please note - you will not receive service payback credit for more than one full-time position in any given month; For multiple part-time positions, PDPDCS will count no more than 40 hours per week; and, creditable service is based on actual time worked, not how you are paid (i.e. work 9 months, paid over 12 months, service credit is 9 months).

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 during your employer’s 30–day verification period until your employer verifies or disputes the record or the 30-day verification window expires.

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

*2. When did this job begin? __________ (mm/dd/yyyy) (You will not be able to enter a date prior to DATE [DISPLAY DATE OF EXIT]. If you began this position prior to the date you exited your program, please enter the DATE [DISPLAY DATE OF EXIT + 1 DAY].

*3. When did this job end? __________ (mm/dd/yyyy)

Please note: Past employment records cannot be edited once submitted and verified by employer. Contact the PDPDCS Helpdesk at 1-888-884-7110 or [email protected] for issues with past employment verification.

*4a. Is this a full-time position?

• Full Time (as defined by your employer)

• This is a summer position

• This position has summers off

• This is a year round position

*4b. Is this a part-time position?

• Part Time (as defined by your employer)

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

*5. Does this employment benefit American Indian/Alaska Native people?

• Yes

• No

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

• General Education Teacher

• Special Education Teacher

• Native Language Teacher (not classified as a classroom teacher)

• Assistant Principal

• Principal

• Administrator – LEA (Local Education Agency)

• Administrator – SEA (State Education Agency)

• Administrator – TEA (Tribal Education Agency)

*7. Please select the most appropriate grade span.

• Pre-K

• K – 5

• 6 – 8

• 9 – 12

• Other (please specify) ____________________

*8. Please select the area(s) of education that best describe this position. Check all that apply.

General Area of Education

 □  Administration
 □  Elementary Education

 □  Secondary Education

 □  Special Education

Subject Area

□  Arts and Music

 □  Bilingual or English as a Second Language

 □  Early Childhood Education

 □  English or Language Arts

 □  Language Education (Native/Heritage/World Language)

 □  Health or Physical Education

 □  Mathematics or Computer Science

 □  Natural Sciences

 □  Social Sciences

 □  Career or Technical Education

 □  Other (please specify) __________

*9. Do you meet the state certification/licensure requirements for this position?

Select the most appropriate answer.

• Yes

• No

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

G. Deferral Request

According to the Program Regulations (in 34 CFR 263.9(b)) available on the PDPDCS website (https://pdp.ed.gov/OIE/Home/Regulation), the Secretary may grant a deferral for repayment of a scholarship under any circumstance in which a participant:

1. is engaging in a full-time course of study at an institution of higher education; or

2. is serving on active duty as a member of the armed services of the United States.

Reason for Deferral

• I am engaging in a full-time course of study at an institution of higher education.

• I am serving an active duty as a member of the armed services of the United States.

[If educational deferment display]

You may request an educational deferment of your service payback if you are continuing as a full-time student without interruption, in a program leading to a degree in an accredited Institution of Higher Education (IHE) or Tribal College of University (TCU). You must request this deferment within the 6-month grace period after leaving the your program.

You must also provide the following information:

1. Name of the accredited institution: ________________________________

2. The degree being sought: _______________________________________

3. Date of program completion: _______________(mm/dd/yyyy)

4. A copy of the letter of admission/Status report [display Status report if deferral is approved from the IHE/TCU] The acceptance letter/status report must state your name, date of acceptance into program of study, the degree being sought, that you are enrolled full-time, be on school letterhead, and be signed and dated by a school official.

You may upload an electronic copy of the required documentation or you may mail or fax the documents to the PDPDCS Help Desk at 1600 Research Blvd., RB 2268, Rockville, MD, 20850 or 888-252-6960.

Please upload the appropriate documentation to support your deferral request. Depending on the file size of the attachment, the upload process may take up to several minutes. Acceptable file types include .doc, .docx., .and pdf. Please note that file names or titles cannot have spaces. You may use underscores (e.g., John_Doe_deferral_request.doc).

If your request is approved, you must submit a status report from an authorized academic advisor or other authorized representative of the IHE/TCU, showing verification of full-enrollment and status after each semester.

[If military deferment display]

You may request a military deferment if you exit your program because you are called or ordered to active duty status in connection with a war, military operation, or national emergency for more than 30 days as a member of a reserve component of the Armed Forces named in 10 U.S.C. 10101, or as a member of the National Guard on full-time National Guard duty, as defined in 10 U.S.C. 101(d)(5). The Secretary may defer the payback requirement until you have completed your military service, for a period not to exceed 36 months. You must request the deferral within 30 days of the earlier of receiving the call to military service or completing or exiting your program.

You must also provide the following information:

1. Date on which service began: ________________ (mm/dd/yyyy)

2. Date on which service is expected to end: ________________ (mm/dd/yyyy)

3. A written statements from your commanding or personnel officer certifying that you are on active duty in the Armed Forms of the United States; the date on which your service began; the date on which your service is expected to end.

4. A true certified copy of your official military orders.

5. A copy of the your military identification.

You may upload an electronic copy of the required documentation or you may mail or fax the documents to the PDPDCS Help Desk at 1600 Research Blvd., RB 2268, Rockville, MD, 20850 or 888-252-6960.

Please upload the appropriate documentation to support your deferral request. Depending on the file size of the attachment, the upload process may take up to several minutes. Acceptable file types include .doc, .docx., .and pdf. Please note that file names or titles cannot have spaces. You may use underscores (e.g., John_Doe_deferral_request.doc).

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