Employment Verification Record

Rehabilitation Services Administration (RSA) Payback Information Management System (PIMS)

Employment Verification Record

(Completed by Employer)

OMB Control Number: 1820-0617

Expiration: TBD

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 1820-0617.  Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  The obligation to respond to this collection is voluntary.  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 Corinna H. Stiles, Chief, Training Programs Unit at (202) 245-6162 or via email at [email protected] directly.

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

The Rehabilitation Services Administration (RSA) Payback Information Management System (PIMS) is an online data collection system designed to facilitate administration of the Rehabilitation Long-Term Training (RLTT) Program, in the Rehabilitation Services Administration, Training Programs Unit at the U.S. Department of Education. This system collects contact information, educational training, funding, and employment from participating scholars to verify the fulfillment of their service obligation and assess program performance. Verifying service obligation requires collecting personally identifying information from universities, scholars, and employers. This data collection has been authorized by P.L. 114-95 section 302 (b) of the Rehabilitation Act of 1973, as amended by the Workforce Innovation and Opportunity Act (WIOA), and the implementing regulations, CFR 386, as well as P.L.103-62 section 4 of the Government Performance and Results Act of 1993.

Users of the PIMS must agree to certain conditions and agree to act to insure the accuracy and confidentiality of the information stored by the PIMS.

Employers using this system agree to:

• Maintain the confidentiality of requested employment information about scholars;

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

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

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 P.L. 114-95 section 302 (b) of the Rehabilitation Act of 1973, as amended by the Workforce Innovation and Opportunity Act (WIOA), and the implementing regulations, CFR 386. We request the scholar’s educational information pertinent to the RLTT 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 RLTT Program is voluntary, but you must provide the requested information, including the scholar’s PII, in order for the student to participate in the RLTT Program. The information will be used to ensure that recipients of scholarships provided with funds under the Rehabilitation Act meet specific statutory and regulatory requirements, including service obligation fulfillment or repayment of financial obligation.

The information in 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.

Employment Verification Page 1

Welcome to the Rehabilitation Services Administration (RSA) Payback Information Management System (PIMS). The scholar listed below accepted a scholarship from a grant awarded to a university by the U.S. Department of Education, Rehabilitation Services Administration (RSA), Training Programs Unit. Acceptance of the scholarship includes a service obligation requirement of two years of eligible employment for each year of financial support. Scholars are required to provide PIMS with annual updates about their employment in order for PIMS to track the fulfillment of their service obligation. For scholars to receive service obligation credit, their employment must be verified by an employer. Additional information about PIMS and the service obligation is available on the PIMS website at https://pdp.ed.gov/RSA.

Please take a moment to verify the accuracy or to correct any inaccuracies of the information provided by the scholar. We anticipate that the survey will take no longer than 10 minutes to complete. Your session will timeout after 30 minutes of inactivity and the information entered will not be saved.

Do NOT use your internet browser's back button during this process. Thank you for taking the time to provide this information.

Employee Name: 

Employer Information (fields are pre-filled)

*Employer’s Name: ______________________________

Department : ________________________________

Employer’s Address

*Address Line 1: Address Line 2:

___________________________ __________________________

*City: *State: *Zip Code:

________________ ___________ ______-____

*Phone: Fax:

_________________ ___________________

TTY:

_____________________

Please provide the Employer’s website address and ensure it includes the prefix http:// or https://.

__________________________________

Supervisor Information

*First Name: *Last Name:

___________________________ __________________________

Supervisor’s Business Address

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ ___________________

*E-mail: *Verify E-mail:

_________________ ________________

Alternative E-mail: Verify Alternative E-mail:

_________________ ___________________

Fax: TTY:

_____________________ _____________________

Human Resource Official Information

*First Name: *Last Name:

___________________________ __________________________

Human Resource Official’s Business Address: 

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ ___________________

*E-mail: *Verify E-mail:

_________________ ________________

Alternative E-mail: Verify Alternative E-mail:

_________________ ___________________

Fax: TTY:

_____________________ _____________________

Title and name of person completing this form:

______________________________

Employment Verification Page 2.

Please review the information below.

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

Employee Name: 

1. What type of organization is this?

Scholar Answer:

Agree □ Disagree □

If you disagree, please explain:

2. Was the scholar employed from _______________ to ____________?

Agree □ Disagree □

If you disagree, please explain:

PLEASE NOTE: We understand that scholars may have begun employment prior to the date listed here. However, according to program regulations, scholars may begin work in eligible employment once the scholar exits or graduates. Therefore, the date indicated above reflects only that employment that began after the scholar’s exit or graduation from his/her program of study. Please verify that the scholar was employed during the dates listed above.

3. What is the scholar’s job title?

Scholar Answer:

Agree □ Disagree □

If you disagree, please explain:

4. Description of scholar’s duties.

Scholar Answer:

Agree □ Disagree □

If you disagree, please explain:

You may also upload a description of the scholar’s duties. Click here to upload a document.

5a. Is/was this full time or part time employment (Full time as defined by you the employer and must be 35 hours or more per week)?

Scholar Answer:

Agree □ Disagree □

If you disagree, please explain:

5b. If this employment is/was part-time, on average, how many hours does the scholar work per week at this job?

Scholar Answer:

Agree □ Disagree □

If you disagree, please explain

Question 6 is confidential and will not be shared with the scholar.

6. At this time, would you rate the scholar’s level of effectiveness in ensuring clients are placed in competitive integrated employment as:

• Effective

• Less than effective

• Ineffective

• Not rated for this position

• Choose not to respond

If you checked DISAGREE next to any of the scholar’s responses, please describe the reason

for your disagreement on the following page. Please include what you believe to be the

correct response. An Employment Dispute Report will be provided to the scholar, and he or

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

I certify that all of the information I have provided is true and correct to the best of my knowledge. I understand that if I purposely give false or misleading information, I may be fined in an amount not less than $5,000 and not greater than $10,000, plus 3 times the amount of damages the Government sustains due to my false statement. - False Claims Act, 31 USC § 3729.

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