Scholar: Pre-Scholarship Agreement

O MB Control Number: 1820-0686

Expiration:

Personnel Development Program Data Collection System

Service Obligation Pre-Scholarship Agreement

For a Scholarship Received from a Personnel Development

To Improve Services and Results for Children with Disabilities Grant

Service Obligation Pre-Scholarship Agreement

Between

_____________________________

Name of Scholar

And

______________________________

Name of Grantee (IHE)

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 part D of the Individuals with Disabilities Education Act, as amended by the Individuals with Disabilities Education Improvement Act of 2004. We request your scholar 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 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 Office of Special Education (OSEP) Personnel Development Program (PDP) is voluntary and that giving us your student educational 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 requirements, including service obligation fulfillment or repayment of your 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 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. Finally, disclosures may be made to OMB as necessary under the requirements of the Credit Reform Act.

Prior to granting a scholarship, the grantee will require each scholar to use the OMB-approved Pre-scholarship Agreement in which the scholar agrees to the terms and conditions set forth in the regulations published on June 5, 2006 implementing section 662(h) of IDEA (see 34 CFR part 304), including the requirement that the Secretary track the service obligations of scholarship recipients. The regulations and the Frequently Asked Questions (FAQs) are also available at https://pdp.ed.gov/OSEP/Home/Regulation and https://pdp.ed.gov/OSEP/Home/faq/.

The U.S. Department of Education has established the Personnel Development Program Data Collection System (PDPDCS). One of the system’s primary responsibilities is to track the service obligations of scholars funded by PDP grants awarded in Federal fiscal year 2005 and any year thereafter.

The PDPDCS’s address is:

OSEP PDP Data Collection System

1600 Research Blvd, RB 2268
Rockville, MD 20850

To Be Completed by the Grantee

Grant Award Number: H325

Grantee:

Project Title:

Course of Study or Program:

Project Director:

Date of Scholarship Assistance and Service Obligation Meeting:

Estimated Total Amount of Training in Academic Years:

Estimated Total Amount of Funding That Will Be Provided:

Date of Enrollment*:

* 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.

Scholar Contact Information

Scholar Name:

Date of Birth:

Social Security Number*:

Permanent Street Address:

Permanent City, State, Zip Code:

Primary E-mail Address:

Do not use a university email address

Alternative E-mail Address:

Cell phone number:

Home phone number:

*Social security number must be redacted after the grantee has entered it into the Personnel Development Program Data Collection System (PDPDCS), and prior to uploading this form into the PDPDCS.

Alternate Contact Information

Address and contact information for a relative or other person through which PDPDCS may contact the scholar, if necessary.

Name:

Relationship:

Street Address:

City, State, Zip Code:

Telephone Number:

E-mail Address:

To Be Completed by Scholar

I have read and agree to the Service Obligation Regulations (34 CFR §304.30 Requirements for Scholar), including statements (a) through (l) below:

1. Upon exiting the training program, I must subsequently maintain eligible employment: 1) on a full-time or full-time equivalent basis; and 2) for a period of at least two years for every academic year for which scholarship assistance was received;

2. I understand that eligible employment is defined as a position in which:

1) At least 51 percent of the infants, toddlers, and children to whom I provide services are receiving special education, related services, or early intervention services from me;

2) I spend at least 51 percent of my time providing special education, related services, or early intervention services to infants, toddlers, and children with disabilities; or

3) If the position involves supervision including in the capacity of a principal, teaching at the postsecondary level, research, policy, technical assistance, program development, or administration, I spend at least 51 percent of my time performing work related to the training I received through my scholarship;

3. I understand that I may begin eligible employment subsequent to completion of the training program or the completion of one academic year of the training for which my scholarship assistance was received;

d) I understand that I will receive credit toward service obligation only after my employer has verified my eligible employment and that I have a responsibility for obtaining verification of eligible employment;

e) I must complete the service obligation within the period ending not more than the sum of the number of years required (at least two years for every academic year for which scholarship assistance was received), plus five additional years, from the date I complete the training (§304.30(f)(1));

f) The U.S. Department of Education may grant a deferral or an exception to the service obligation or repayment requirements upon request (§304.23(a)), if I can provide sufficient evidence to substantiate eligibility;

7. Within 30 days of completion of my training, I will inform the U.S. Department of Education of my intention to (1) complete my service obligation through eligible employment (by logging into the Personnel Development Program Data Collection System (PDPDCS) at https://pdp.ed.gov/OSEP) or (2) repay the total amount of funding received (by contacting the PDPDCS Help Desk at [email protected] or 1-800-285-6276);

8. I understand that, under section 304.30(j)(4), I will enter repayment status and be referred for repayment to the U. S. Department of Education, Accounts Receivable and Bank Management Group when:

1) I inform the grantee representative or the U. S. Department of Education that I do not plan to fulfill the service obligation under this agreement;

2) I fail to begin or maintain employment making it impossible to complete the service obligation within the number of years required; or

3) I discontinue enrollment in the course of study at the educational institution or agency designated in my scholarship; (Note: This provision does not apply if I have completed at least one year of a program that is more than one year in duration.);

7. I have completed the Certification of Eligibility for Federal Assistance form (ED 80-0016);

8. I understand there is no guarantee of federal funding for the duration of my training;

9. I have received and read the Frequently Asked Questions; and

10. I agree to comply with the requirement to provide the information necessary to the U. S. Department of Education to track my service obligation, including social security number, address, employment setting, and employment status (§304.30(h)(i)).

______________________________ _______________________________ ____________

Scholar Name Scholar Signature Date

(Please print)

To be Completed by Grantee Representative

I have met with the scholar and discussed the service obligation requirements and provided the scholar with a copy of the regulations and the FAQs.

____________________________ ___________________­­­­­­­­________ _______

Grantee Representative Name Grantee Representative Signature Date

(Please print)

Note: Within 30 days of enrollment, the completed and signed Pre-scholarship Agreement must be uploaded into the PDPDCS at https://pdp.ed.gov/OSEP. Please note that all pages must be completed and uploaded for the Pre-Scholarship Agreement to be valid.

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