# Personnel Development Program Data

**Collection System: Scholar/Obligee**  **Employ ment**  **Record Form**

**(Completed by**

**Scholar/Obligee)** OM B Control Number: 1820 - 0686 Ex piration: 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 in formation is estimated to average 1 5 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., S W, W ashington, DC 20210 - 4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1820 - 0686 . Note: Please do not return the completed Scholar/Oblige e Employment Record Form application to this address.OM B Control Number: 1820 - 0686 Expiration: XX

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### 1 

### Rules of Behavior for Department of Education **- Sponsored Website**  The Personnel Development Program (PDP) Data Col lection 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 employ me nt 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 Vol um e 71 No. 107 June 5, 2006 , and the Government Performance and R esults Act of 1993, section 4. Scholars/obligee s using this system agree to:

 Maintain requested contact and employ me nt information  Maintain their DCS accounts by: o Protecting account login names and passwords ; o Subm itting accurate information for current address, phone number, employ me nt status and employer information ; and o Using the DCS only to access their own information. By agreeing to these Rules of Behavior, scholars/obligee s agree to maintain the confidentiality of this information. Violation of th is policy will result in suspension of scholar/obligee access to the DCS. 

## □ **I agree to the terms.**OM B Control Number: 1820 - 0686 Expiration: XX

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### 2 **Employment Record Form Employment Information**  The questions relating to your employ me nt affect your obligation fulfillment status. You must answer ever y 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 employ me nt 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. Wh at 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.OM B Control Number: 1820 - 0686 Expiration: XX

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### 3 **Empl oy**  **er Information**  You m ust provide the name, address, and phone number of the employer organization for this position. If your employ me nt position is outside of the United States, please contact the DCS Helpdesk to report your employ me nt information. Yo u mu st list **at least one** supervisor or hum an resources ma nager who can verify your employment and provide his or her e - ma il address. You will be asked on the next page to indicate which contact should be sent your em ploy me nt record for verification.

*Organization Name: ______________________________ Department Name: ________________________________ Organization Address *Address Line 1: Address Line 2:



### ___________________________ __________________________ *Cit y: *State: *Zip Co de:



### ________________ ___________ ______-

____ *Phone: Fax:



### _________________ (xxx - xxx - xxxx) ___________________ (xxx - xxx - xxxx) TTY : _____________________ (xxx - xxx - xxxx) Organization We b site address: (Ensure the W eb site has the prefix "http://".):

__________________________________OM B Control Number: 1820 - 0686 Expiration: XX

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### 4 **Supervisor** Please provide the name of a supervisor at this job who can verify this employ ment information
. * First: * Last:



### ___________________________ __________________________ Supervisor’s Business Address Address Line 1: Address Line 2:



### ______________

_____________ __________________________ Cit y: State: Zip Co de:



### _______________

_ ________ ___ ______-

____ Phone: Mobile Phone :



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

* E - ma il: * Verify E - ma il:



### _________________ ________________ Alternative E - ma il Address: Ver ify Alt. E - ma il:

**_________________ ___________________** 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 em ploy me nt information.

* First: * Last:



### ___________________________ __________________________ Human Resource Business Manager’s Address: Address Line 1: Address Line 2:



### ___________________________ __________________________ Cit y: State: Zip Co de:



### ________________ ___________ _____ _-

____ Phone: Mobile Phone:



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

* E - ma il: * Verify E - ma il:



### _________________ ________________ Alternative E - ma il Address: Verify Alt. E - ma il:

**_________________ ___________________**  Fax: TTY: _____________________ (xxx - xxx - xxxx) _____________________ (xxx - xxx - xxxx)OM B Control Number: 1820 - 0686 Expiration: XX

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### 5 Em ploy me nt Information Please note that past employ me nt records cannot be edited once submitted for verification. Your em ployer will have 30 days from the date of submission to verify or dispute your employ me nt information for this position. Current employ me nt recor ds can be edited. You will receive credit for current employ me nt up to the date of last update. You cannot update your current employ me nt 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 yo u 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, plea se click the "Save For Later" button at the bottom of the page. 1. * Is this your current employment?

o Yes o No
*Wh en did this job begin? (mm/dd/yyyy) Wh en did this job end? (mm/dd/yyyy)

Please note : past employment records cannot be edited once submitted. 2. *Wh ich 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 Adm inistrator/coordinator/ s upervisor (including the capacity of a principal) o Instructional s pecialist 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 employ me nt 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 em ploy me nt position.OM B Control Number: 1820 - 0686 Expiration: XX

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### 6 I. Special Educatio n II. Related Services
□ General special education, cross - categorical, generic, m ulti c a t egorical, or non - categorical □ General special education, mil d or moderate □ Low - incidence disabilities/multiple disabilities/sev e re disabilities □ Combined studies: General educ a tio n and special education □ Dev e lopmental delay □ Specifi c lear n i n g disabilities □ Speech/language impairment □ Em otional dis t urbance/behavioral disorders □ Autism □ Traumatic brain injury □ Deafness and/or hard - of- hearing □ Visual impair m ent and/or blindness □ Deaf- blin d ness □ Intellectual disability: Mild / m o derate □ Intellectual disability : Severe □ Other health impairme n t □ Ph ys ical im pairment/orthopedic impairment □ Adapted physical e ducation □ Assistive technology □ Bilingual sp e cia l education/ESL/TESOL □ Early childhood/early intervention □ Special education for youth i n correctional facilities □ Secondary t ransition □ Audiology □ Counseli n g □ Educational diagnostician □ Interpreter/AS L □ Music therapy □ Nursing □ Occ u pational therapy □ Or i entat i o n & mobility □ Paraprofessional □ Ph ys ical therapy □ Rehab i litation counseling □ School counseling □ Psy chology □ Speech/l a nguage □ Social work □ Therapeutic recreation □ W orkexperience coordinator (em p loy me nt transition speciali s t)

If the special education and related services areas above are not appropriate for the training focus of your em ploy me nt, please provide a brief description of the area of focus for this employ ment.OM B Control Number: 1820 - 0686 Expiration: XX

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### 7 5. If appropriate, select up to three additional training areas to provide more detailed information about this employ me nt position. I. Special Educat ion II. Related Services
□ General special education, cross - categorical, generic, multi categorical, or non - categorical □ General special education, mild or moderate □ Low- incidence disabilities/multiple disabilities/severe disabilities □ Combined studies: General educatio n and special education □ Developmental delay □ Specific learning disabilities □ Speech/language impairment □ Em otional 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 □ Ph ys ical im pairment/orthopedic impairment □ Adapted physical education □ Assistive technology □ Bilingual specia l education/ESL/TESOL □ Early childhood/early intervention □ Special education for youth in correctional facilities □ Secondary t ransition □ Audiology □ Counseling □ Educational diagnostician □ Interpreter/ASL □ Music therapy □ Nursing □ Occupational therapy □ Orientation & mobility □ Paraprofessional □ Ph ys ical therapy □ Rehabilitation counseling □ School counseling □ Psy chology □ Speech/language □ Social work □ Therapeutic recreation □ W o rkexperience coordinator (employ me nt transition specialist)

Please answer the questions below that best describe the work you do in this position. Eligible em ploy me nt 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)
.OM B Control Number: 1820 - 0686 Expiration: XX

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### 8 6. Please complete Questions 6a
. and 6b
. only if you selected one of the following answers for Question 2 : Wh ich 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 sp ecial 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 em ergency , temporary or provisional basis ? Select the most appropriate answer. "Highly qualified/qualified/fully certified" for purposes of this data collection means that the employee me ets 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 requiremen t s for certification/licensure for this position o Not applicable to this type of employ me nt 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 s chool 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 - ma il of the em ployer contact(s) you would like to receive the verification request: