Personnel Development Program Data 

Collection System: Scholar/Obligee 

Employment Record Form

(Completed by Scholar/Obligee)

OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

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. 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 required to obtain or maintain benefits (Individuals with Disabilities Education 

Act of 2004 (IDEA) and its corresponding requirements, 34 CFR Part 304). Send comments regarding the burden 

estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the 

U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email ICDocketMgr@ed.gov 

and reference the OMB Control Number 1820-0686. Note: Please do not return the completed Scholar/Obligee 

Employment Record Form application to this address.
OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

1

Rules of Behavior for Department of Education-Sponsored Website

The Personnel Development Program (PDP) Data Collection System (DCS) 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 employment and 

contact information from participating scholar/obligees 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/obligees, and employers. This data collection 

has been authorized by the Individuals with Disabilities Education Act of 2004 (IDEA) and its 

corresponding regulations printed in the Federal Register Volume 71 No. 107 June 5, 2006, and the 

Government Performance and Results Act of 1993, section 4.

Scholars/obligees using this system agree to:

 Maintain requested contact and employment information 

 Maintain their DCS accounts by:

o Protecting account login names and passwords;

o Submitting accurate information for current address, phone number, employment status 

and employer information; and

o Using the DCS only to access their own information.

By agreeing to these Rules of Behavior, scholars/obligees agree to maintain the confidentiality of this 

information. Violation of this policy will result in suspension of scholar/obligee access to the DCS.

□ I agree to the terms.
OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

2

Employment Record Form

Employment Information

The questions relating to your employment affect your 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.

1. Does your current or previous employment fulfill your service obligation?

o Yes 

o No 

 

Employment Information

2. Is this position a substitute teaching position?

o Yes 

o No

 

Organization Type

1. What type of organization is this?*

o Public School 

o Residential School 

o For-profit or Commercial 

Organization

o Federal Government Agency

o State or Local Government 

Agency 

o Private School

o Hospital

o College/University

o Non-Profit Organization

o Other, Please Specify:_____________

If respondent selects “Public School” above, display Common Core of Data search functionality, or

proceed with open text fields.
OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

3

Employer Information

You must provide the name, address, and phone number of the employer organization for this 

position. If your employment position is outside of the United States, please contact the DCS

Helpdesk to report your employment information. 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 contact should be sent your 

employment record for verification. 

*Organization Name: ______________________________

 Department Name: ________________________________

 

Organization Address

*Address Line 1: Address Line 2:

 ___________________________ __________________________

*City: *State: *Zip Code:

 ________________ ___________ ______-____

*Phone: Fax:

 _________________ (xxx-xxx-xxxx) ___________________ (xxx-xxx-xxxx)

TTY: 

_____________________ (xxx-xxx-xxxx) 

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

__________________________________ 
OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

4

Supervisor

Please provide the name of a supervisor at this job who can verify this employment 

information.

*First: *Last: 

 ___________________________ __________________________

Supervisor’s Business Address

Address Line 1: Address Line 2:

 ___________________________ __________________________

City: State: Zip Code:

 ________________ ___________ ______-____

Phone: Mobile Phone:

 _________________ (xxx-xxx-xxxx) ___________________ (xxx-xxx-xxxx)

*E-mail: *Verify E-mail:

 _________________ ________________

 

 Alternative E-mail Address: Verify Alt. E-mail:

_________________ ___________________

Fax: TTY: 

_____________________ (xxx-xxx-xxxx) _____________________ (xxx-xxx-xxxx)

Human Resource Manager

Please provide the name of a human resources manager at this job who can verify this 

employment information.

*First: *Last: 

 ___________________________ __________________________

Human Resource Business Manager’s Address:

Address Line 1: Address Line 2:

 ___________________________ __________________________

City: State: Zip Code:

 ________________ ___________ ______-____

Phone: Mobile Phone:

 _________________ (xxx-xxx-xxxx) ___________________ (xxx-xxx-xxxx)

*E-mail: *Verify E-mail:

 _________________ ________________

 

 Alternative E-mail Address: Verify Alt. E-mail:

_________________ ___________________

Fax: TTY: 

_____________________ (xxx-xxx-xxxx) _____________________ (xxx-xxx-xxxx)
OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

5

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 

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

the 30-day verification window expires. Also note that per 2006 Regulations §304.30(f)(2), you will not 

receive credit for work completed prior to the date when you completed one academic year of training.

Classroom teachers with 12 month contracts must indicate 12 months of employment to receive a year 

of service obligation credit. If you enter the start and end dates of the school year you will only receive 

credit for the number of months entered.

Question #7 does not affect your service obligation fulfillment status. This question is for measuring 

performance of the programs 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?

o Yes 

o No

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

 

 

Please note: past employment records cannot be edited once submitted.

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

o Special education teacher

o Early intervention, early childhood, or early childhood service provider

o Special education paraprofessional/aide

o Early intervention, early childhood special education, or early childhood 

paraprofessional/aide

o Related or supportive service provider in early intervention, early childhood or in a school 

setting

o Related or supportive service provider in a non-school setting (e.g., child find services)

o Administrator/coordinator/supervisor (including the capacity of a principal)

o Instructional specialist

o Higher education (e.g., faculty, research assistant, practicum coordinator) 

o Other, within education (please specify________________________)

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

3a. Full Time (As defined by your Employer) 

o This is a summer position

o This position has summers off

o This is a year round position

3b. Part Time

o If this employment is part-time, on average, how many hours does the 

scholar/obligee work per week at this job? ______

4. Select one special education and/or related services training area that best describes this 

employment position. 
OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

6

I. Special Education II. Related Services 

□ General special education, cross-categorical, generic, multicategorical, or non-categorical

□ General special education, mild or moderate

□ Low-incidence disabilities/multiple disabilities/severe 

disabilities

□ Combined studies: General education and special education

□ Developmental delay

□ Specific learning disabilities

□ Speech/language impairment

□ Emotional disturbance/behavioral disorders

□ Autism

□ Traumatic brain injury

□ Deafness and/or hard-of-hearing

□ Visual impairment and/or blindness

□ Deaf-blindness

□ Intellectual disability: Mild/moderate

□ Intellectual disability: Severe

□ Other health impairment

□ Physical impairment/orthopedic impairment

□ Adapted physical education

□ Assistive technology

□ Bilingual special education/ESL/TESOL

□ Early childhood/early intervention

□ Special education for youth in correctional facilities

□ Secondary transition

□ Audiology

□ Counseling

□ Educational diagnostician

□ Interpreter/ASL

□ Music therapy

□ Nursing

□ Occupational therapy

□ Orientation & mobility

□ Paraprofessional

□ Physical therapy

□ Rehabilitation counseling

□ School counseling

□ Psychology

□ Speech/language

□ Social work

□ Therapeutic recreation

□ Work experience coordinator (employment 

transition specialist)

If the special education and related services areas above are not appropriate for the training focus of your 

employment, please provide a brief description of the area of focus for this employment.
OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

7

5. If appropriate, select up to three additional training areas to provide more detailed information 

about this employment position.

I. Special Education II. Related Services 

□ General special education, cross-categorical, generic, multicategorical, or non-categorical

□ General special education, mild or moderate

□ Low-incidence disabilities/multiple disabilities/severe disabilities

□ Combined studies: General education and special education

□ Developmental delay

□ Specific learning disabilities

□ Speech/language impairment

□ Emotional disturbance/behavioral disorders

□ Autism

□ Traumatic brain injury

□ Deafness and/or hard-of-hearing

□ Visual impairment and/or blindness

□ Deaf-blindness

□ Intellectual disability: Mild/moderate

□ Intellectual disability: Severe

□ Other health impairment

□ Physical impairment/orthopedic impairment

□ Adapted physical education

□ Assistive technology

□ Bilingual special education/ESL/TESOL

□ Early childhood/early intervention

□ Special education for youth in correctional facilities

□ Secondary transition

□ Audiology

□ Counseling

□ Educational diagnostician

□ Interpreter/ASL

□ Music therapy

□ Nursing

□ Occupational therapy

□ Orientation & mobility

□ Paraprofessional

□ Physical therapy

□ Rehabilitation counseling

□ School counseling

□ Psychology

□ Speech/language

□ Social work

□ Therapeutic recreation

□ Work experience coordinator (employment 

transition specialist)

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 §304.30(e) of the 2006 Program 

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).
OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

8

6. Please complete Questions 6a. and 6b. only if you selected one of the following answers for Question 

2: Which of the following best describes the position?:

o Teacher 

o Early intervention, early childhood, or early childhood service provider 

Paraprofessional/aide 

If you did not select one of the above responses in Question 2, please complete Question 6c.

6a. *Describe the percentage of time spent teaching or serving special education students in this 

position.

o 50% or less

o At least 51% 

6b. *Describe the percentage of special education students taught or served in this position.

o 50% or less

o At least 51% 

6c. *Describe the percentage of time spent performing work related to the training for which the 

scholarship was received under section 662 of IDEA the Individuals with Disabilities 

Education Act of 2004 in this position.

o 50% or less

o At least 51% 

7. *Are you "highly qualified/qualified/fully certified" for this position under Individuals with Disabilities 

Education Act (IDEA) and have not had certification or licensure requirements waived on an 

emergency, temporary or provisional basis? Select the most appropriate answer.

"Highly qualified/qualified/fully certified" for purposes of this data collection means that the employee 

meets the state requirements (if there are requirements in your state) for certification/licensure for this 

position.

o {Highly qualified/qualified/fully certified}

o {Not highly qualified/Not qualified/Not fully certified}

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

o Not applicable to this type of employment position 

Note: If the position is an elementary or secondary general education/special education teacher, the 

employee can be "highly qualified." If the position is general education/special education 

paraprofessional/aide or early intervention, early childhood or preschool paraprofessional/aide, the 

employee can be "qualified." If the position is administrator/coordinator, for related or supportive services 

in a school setting, or for teacher, related services, or supportive services in early intervention, early 

childhood, the employee can be "fully certified.”

Please provide the name and the e-mail of the employer contact(s) you would like to receive the 

verification request: