Exit Certification

Personnel Development Program Data Collection System

Service Obligation Exit Certification

For a Scholarship Received from a Personnel Development

To Improve Services and Results for Children with Disabilities

Grant Awarded in Fiscal Year 2006 and Any Year Thereafter

Service Obligation Exit Certification

Between

_____________________________

Name of Scholar

And

______________________________

Name of Grantee (IHE)

Grant Award Number: ____________________________________

Grantee Representative: ________________________________

Project Title: _______________________________________

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 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 required to obtain or retain benefits 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.

Upon completion or exit from grant-supported training, the grantee will require each scholar to use the OMB-approved Exit Certification (#1820-0686) 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 Frequently Asked Questions (FAQs) are available at https://pdp.ed.gov/OSEP/Home/Regulation and https://pdp.ed.gov/OSEP/Home/faq/.

The U.S. Department of Education established the Personnel Development Program Data Collection System (PDPDCS). One of the Center'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 address is:

OSEP PDP Data Collection System

1600 Research Blvd, RB 2268
Rockville, MD 20850

Service Obligation Information and Exit Certification

Below you must enter the service obligation details for the scholar. This information is critical to tracking service obligation fulfillment. Note that after the completion of at least one academic year of training, a scholar may begin to fulfill his or her service obligation according to the 2006 Regulations, section 304.30(f)(2). An academic year is defined by the program regulations as "(1) A full-time course of study- (i) Taken for a period totaling at least nine months; or (ii) Taken for the equivalent of at least two semesters, two trimesters, or three quarters; or (2) For a part-time scholar, the accumulation of periods of part-time courses of study that is equivalent to an ‘academic year’ under paragraph (a) (1) of this definition." 2006 Regulations, section 304.3(a)(1)(2).

According to section 304.31(a)(b), the Secretary may grant a deferral or an exception to the work or repayment requirements upon request, if a scholar can provide sufficient evidence to substantiate eligibility.

Scholars who exit a training program prior to completion and have not finished at least one academic year of training will be referred for repayment to the Accounts Receivable and Bank Management Division (ARBMD) of the U.S. Department of Education. Scholars will not receive credit for any employment positions held prior to the date of completion of one academic year. However, if a scholar completes a training program that is less than one academic year in duration, she or he may repay through service. See 2006 Regulations: section 304.30(f)(2), (j)(4)(iii).

This information must match what is reported by the grantee in Sections I and G of the scholar’s record in the Personnel Development Program Data Collection System (PDPDCS).

1. Scholar program status: Select the most appropriate option below.

○ The scholar exited/graduated/completed the program.

*Please enter the date of exit/gradation/completion:

○ The scholar exited without graduating/completing the program.

*Please enter the date of exit without completion:

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: __________

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: *

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 48 months (or four years) of service obligation.

5. Total amount of funding this scholar received directly from this OSEP-supported training grant (See section 304.21(a) and (b) for allowable costs):

Enter the amount of funding in dollars and cents.

6. Date by which service obligation must be completed*

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.

__________________

*For these items, please report the number of months and date calculated and displayed in Section I of the Scholar Record in the PDPDCS.

To be completed by the Grantee Representative and Scholar upon exiting or completing the program:

Scholar Contact Information

Scholar Name
Scholar Address after Completing or Exiting the Program
Scholar E-mail Addresses after Completing or Exiting the Program
Scholar Telephone Number after Completing or Exiting the Program
Name, phone number, address and e-mail address for the scholar’s family member or friend who can forward mail, if necessary
Scholar’s employer, if known (Agency name, contact name, address, and telephone number)

I certify that the Service Obligation Information in this Exit Certification is correct.

____________________________________ ______________

Grantee Representative Signature Date

I understand, agree, and certify that the Service Obligation and Contact Information in this Exit Certification are correct.

_________________________ ______________________ ______________

Scholar Name Scholar Signature Date

(Please print)

Note: The completed and signed Exit Certification must be certified within 30 days of completion or exit from the program by both the grantee and the scholar and uploaded into the PDPDCS at https://pdp.ed.gov/OSEP. Please note that all pages must be completed and uploaded for the Exit Certification to be valid.

Page 5 of 5