OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

Indian Education

Professional Development Grants Program

U.S. Department of Education

Participant Follow-Up Protocol 

Introduction 

The Indian Education Professional Development (IE PD) Grants program provides grants to prepare and 

train Indians to serve as teachers and school administrators. Individuals trained under this program must 

perform work related to their training that benefits Indian people or repay all or a portion of the cash 

value of training costs. 

In 1993 the Government Performance Results Act (GPRA) was passed that requires federally funded 

agencies to develop and implement an accountability system based on performance measurement. 

Grantees are required to report on their progress toward meeting the performance measures established 

for each U.S. Department of Education (ED) grant program. The Office of Indian Education (OIE) 

maintains responsibility for reporting all data for the six IE PD GPRA measures. However, to do so, OIE 

requires supporting information from IE PD grantees, participants and principals/LEA representatives.

This appendix contains proposed program office data collection protocols for participants, such that the 

program office can adequately and accurately complete annual reporting on GPRA measures. Data 

collection also will be used to help ensure participants are fulfilling program requirements with regard to 

service payback. IE PD program staff will conduct the participant data collection and maintain all data. 

Data collection will begin either because a) the participant contacted IE PD program staff to inform staff 

of his/her post-project placement or b) the program office initiated contact with the participant after the 

project informs IE PD program staff that the participant has exited project training. IE PD program staff 

will not use this protocol to follow up with participants who are in an approved and active deferment of 

their service payback requirement. The protocol is not relevant for these participants because the program 

office already knows their education and employment status. 

For each participant who is not in an approved and active deferment, the first round of data collection 

must occur within 6 months of exiting project training. Data collection will occur 6 months after the 

initial contact and every 6 months thereafter until the participant either completes his or her service 

payback requirement or moves into cash payback. 

For example, participant Jane Doe exits project training in May 2009. Therefore, the initial 6 month 

follow-up deadline for Jane Doe is in November 2009. However, Jane Doe informs IE PD program staff 

in August 2009 of an appropriate employment placement. The IE PD program staff will contact Jane Doe 

again in February 2010 and every 6 months thereafter until Jane fulfills her service payback requirement 

or moves into cash payback. 

There are two versions of the Participant Follow-Up Protocol to reflect the two contact options. The IE 

PD program staff should use Version A if they initiate contact with the participant either via telephone or 

email. Version B should be used if the participant initiates contact with the IE PD program office via 

telephone or email. 
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

Participant Follow-Up Protocol 

Version A: Program Office Initiates Contact with a Participant

Instructions to IE PD staff 

Prior to contacting a participant, the IE PD staff needs to review program office records and determine the 

following information for each participant:

 Whether the participant is in an approved and active deferment of his/her service payback 

requirement. That is, a deferment was approved by the program office and is still ongoing.

 Grantee project name;

 The participant’s name, date of birth, and last 4 digits of the Social Security Number (SSN) from

the most recent Semi-Annual Participant Report (SAPR) provided by the grantee; and 

 Whether this contact will be the first contact between the participant and the IE PD staff since the 

participant exiting project training.

If an individual is in an approved and active deferment of his/her service payback requirement, the IE PD 

program staff do not need to contact the individual to complete the Participant Follow-Up Protocol. For 

all other participants, the IE PD staff should pre-fill the relevant parts of the protocol with the grantee 

project name, the participant’s name, date of birth, last 4 digits of the SSN, and whether this is the first 

contact between the participant and IE PD program staff. 

Program office staff will utilize participant contact information provided by grantees to initiate follow up 

with participants who have not contacted IE PD within 6 months of exiting project training. Grantees are 

instructed to provide:

1) Participant name

2) Participant address

3) Participant Social Security Number (used to verify identity)

4) Participant date of birth (used to verify identity)

5) Participant email address

6) Participant telephone number

7) Participant cell phone number, if applicable

8) Participant maiden name, if applicable

9) Alternate contact name

10) Alternate contact address

11) Alternate contact email address

12) Alternate contact telephone number

13) Alternate contact cell phone number, if applicable

IE PD program staff first will use the participant’s telephone number to attempt contact with the 

participant. If, after three attempts, the program office cannot contact the participant, staff will use the 

participant’s cell phone number, if a cell phone number is provided. If, after three attempts, the program 

office cannot contact the participant, staff will use the participant’s email address and attempt contact at 

least three times by email. If these (i.e., telephone and email) contact attempts are unsuccessful, program 

office staff will send a registered letter to the participant at the address provided. This letter will advise 

the participant of the responsibilities attached to participation in IE PD project training and all possible 

consequences for the participant if compliance with responsibilities is not obtained. 

If none of these attempts results in contact with the participant, program office staff will use the alternate 

contact’s telephone number to contact someone whom the participant indicated would “always know 
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

where he/she was.” If, after three attempts, the program office still cannot confirm contact information 

for the participant, staff will use the alternate contact’s cell phone number, if a cell phone number is 

provided. If, after three attempts, the program office cannot confirm contact information for the 

participant, staff will use the alternate contact’s email address (if available) and attempt contact at least 

three times by email. If these contact attempts are unsuccessful, program office staff will send a 

registered letter to the alternate contact at the address provided. This letter will inform the alternate 

contact of the participant’s participation in IE PD training, the need to achieve follow up with the 

participant, and request the participant’s current contact information. 

If communication with the alternate contact occurs and results in new contact information for the 

participant, program staff will attempt contact with the participant utilizing the new contact information 

provided by the alternate contact and following the above described procedures. If, after exhausting all 

modes of contact, the program office has not achieved contact with the participant, the program office 

will submit participant name and contact information to the appropriate internal ED staff (i.e., ED’s Debt 

Management Office) for follow up.

Once participant contact has been achieved, IE PD program staff should proceed with follow-up questions 

in the protocol. If contact is established by telephone, proceed with the telephone protocol as outlined in 

Version A. If contact is established by email, IE PD program staff should reply with the introduction 

described in Version A, sub-section A, followed by the questions in sections A, B, and C of the Version A 

protocol. 

All data collection activities will be conducted in full compliance with ED regulations. Data 

collection activities will be conducted in compliance with The Privacy Act of 1974, P.L. 93-579, 

5 USC 552a; and, as appropriate, the Federal common rule or ED’s final regulations on the protection of human 

research participants. This is to maintain the confidentiality of data obtained on private persons and to protect the 

rights and welfare of human research subjects as contained in ED regulations. 

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. Public reporting burden for this collection 

of information is estimated to average 30 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 benefit (Elementary and 

Secondary Education Act of 1965, as amended by the No Child Left Behind Act of 2001, Title VII, Part A, Subpart 

2, Secs. 7121-7122; 20 U.S.C. 7441 - 7442, and the Government Performance Results Act (GPRA) of 1993, Section 

4 (1115)). 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 1810-0698. 

Note: Please do not return the completed Participant Follow-up to this address.

INTRODUCTION
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

Good (morning/afternoon/evening). My name is __________________ of the U.S. Department of 

Education. I am calling on behalf of the Indian Education Professional Development program. I am 

calling because our records indicate you participated in this program through the 

_________________________ project (INSERT GRANTEE PROJECT NAME). As you may know, 

on-going contact between project participants and the Indian Education Professional Development 

program after exiting project training is a requirement of program participation. I am calling to collect 

some required information from you about your employment and educational status. First, I need to 

confirm your name, date of birth, and the last 4 digits of your Social Security Number for our records. 

First name: 

Last name: 

Date of birth: 

Last 4 digits of SSN 

COMPLTE THE CONTACT STATUS INSTRUCTION BOX BEFORE CONTACTING THE 

PARTICIPANT. 

CONTACT STATUS INSTRUCTION BOX 

CHECK HERE □IF THIS IS THE FIRST FOLLOW-UP CONTACT SINCE THE PARTICIPANT 

EXITED THE PROJECT AND USE “SINCE YOU EXITED THE INDIAN EDUCATION 

PROFESSIONAL DEVELOPMENT PROJECT” FOR THE TEXT WHERE NOTED IN THE 

QUESTIONS THROUGHOUT THE SURVEY.

OTHERWISE USE “SINCE OUR LAST CONTACT” FOR THE TEXT WHERE NOTED IN THE 

QUESTIONS. 

PRE-FILL USING 

DATA FROM MOST 

RECENT SAPR
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

SECTION A: EDUCATION ENROLLMENT INFORMATION

A.1. Are you currently enrolled full time in a degree-granting program at a community college, college, 

or university?

Yes .................................................. 1 GO TO A.2

No .................................................... 2 SKIP TO A.4

A.2. Were you enrolled full time in a degree-granting program at any other community college, college, 

or university [since you exited the Indian Education Professional Development project/since our 

last contact]?

Yes .................................................. 1 

No .................................................... 2 

A.3. To be considered for deferment for your Indian Education Professional Development service 

payback requirement, you need to submit a written request to the program office. This request must 

include a copy of the letter of admission from the institution, the degree being sought, and the 

projected date of completion. If deferment is granted, you must submit a status report, showing 

verification of enrollment and status, from an academic advisor or other authorized representative at 

the institution of higher education in which you are enrolled. This status report is to be submitted 

after every grading period. Please send the written request to __________________ [YOUR 

NAME] at Indian Education Professional Development Grants Program, U.S. Department of 

Education, 400 Maryland Avenue, SW, Washington, DC 20202-6510. 

CHECK HERE □ AFTER READING STATEMENT AND SKIP TO B.1.
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

A.4. [Since you exited the Indian Education Professional Development project/Since our last contact,] 

were you ever enrolled full time in a degree-granting program at a community college, college, or 

university?

Yes .................................................. 1 GO TO A.5

No .................................................... 2 SKIP TO B.1

A.5. To be considered for deferment for your Indian Education Professional Development service 

payback requirement, you need to submit a written request to the program office. This request must 

include a copy of the letter of admission from the institution, the degree being sought, and the 

projected date of completion. If deferment is granted, you must submit a status report, showing 

verification of enrollment and status, from an academic advisor or other authorized representative at 

the institution of higher education in which you are enrolled. This status report is to be submitted 

after every grading period. Please send the written request to __________________ [YOUR 

NAME] at Indian Education Professional Development Grants Program, U.S. Department of 

Education, 400 Maryland Avenue, SW, Washington, DC 20202-6510. 

CHECK HERE □ AFTER READING STATEMENT AND CONTINUE WITH SECTION B.

SECTION B: EMPLOYMENT EXPERIENCE

B.1. Are you currently employed? 

Yes .................................................. 1 GO TO B.2

No .................................................... 2 SKIP TO B.10

B.2. Are you employed at a school or local educational agency (LEA)? 

Yes .................................................. 1 GO TO B.3

No .................................................... 2 SKIP TO B.10

B.3. Are you employed full or part time in this school or LEA?

Full time .......................................... 1

Part time .......................................... 2 

B.4. What is the name and address of the school where you are currently employed? 

School name: __________________________________

School address: ________________________________
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

B.5. If applicable, what is the name and address of the LEA where you currently are employed? 

LEA name: ___________________________________

LEA address: __________________________________

READ: Please be advised that one of the requirements of your service payback agreement is to 

ensure that the Indian Education Professional Development program office receives verification 

of your employment in an approved LEA. We will send you an Employment Verification Form 

that should be given to your principal, if you are a teacher or vice principal, or an LEA 

representative, if you are a principal, to complete and submit to us. 

B.6. [Since you exited the Indian Education Professional Development project/Since our last contact,] 

were you employed at another school or LEA? 

Yes .................................................. 1 GO TO B.7

No .................................................... 2 SKIP TO C.1

B.7. What was/were the name(s) and address(es) of the school(s) where you were previously employed? 

School name: __________________________________

School address: ________________________________

REPEAT AS NECESSARY FOR ADDITIONAL SCHOOLS

B.8. If applicable, what was/were the name(s) and address(es) of the LEA(s) where you were previously 

employed? 

LEA name: ___________________________________

LEA address: __________________________________

REPEAT AS NECESSARY FOR ADDITIONAL LEAS

B.9 Were you employed full or part time in the school(s) or LEA(s)?

Full time .......................................... 1 

Part time .......................................... 2 

REPEAT AS NECESSARY FOR ADDITIONAL SCHOOLS OR LEAS
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

READ: If you were employed in an approved LEA for the service payback requirement, you may 

be able to use this employment to fulfill some or your entire service payback obligation. To do 

so, you must give an Employment Verification Form to the principal or LEA representative under 

whom you worked to verify the nature and duration of your employment. We will send you the 

Employment Verification Form that should forward to the appropriate individual to complete and 

submit to us. 

SKIP TO C.1

B.10. [Since you exited the Indian Education Professional Development project/Since our last contact,] 

were you ever employed at a school or LEA ?

Yes .................................................. 1 GO TO B.11

No .................................................... 2 SKIP TO C.1

B.11. What was/were the name(s) and address(es) of the school(s) or LEA(s) where you were previously 

employed? 

School name: __________________________________

School address: ________________________________

LEA name: ___________________________________

LEA address: __________________________________

REPEAT AS NECESSARY FOR ADDITIONAL SCHOOLS AND LEAS

B.12 Were you employed full or part time in the school(s) or LEA(s)?

Full time .......................................... 1 

Part time .......................................... 2 

REPEAT AS NECESSARY FOR ADDITIONAL SCHOOLS OR LEAS

READ: If you were employed in an approved LEA for the service payback requirement, you may 

be able to use this employment to fulfill some or your entire service payback obligation. To do 

so, you must give an Employment Verification Form to the principal or LEA representative under 

whom you worked to verify the nature and duration of your employment. We will send you the 

Employment Verification Form that should forward to the appropriate individual to complete and 

submit to us. 

CONTINUE WITH SECTION C.
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

SECTION C: FOLLOW-UP CONTACT INFORMATION

C.1. As part of the service payback requirement, we will need to hear from you again in 6 months. We 

would like to update your contact information for our files. Please tell me you current address, 

telephone number, and email address:

Address: 

Number Street Apt. No.

City State Zip Code

REFUSED........................................ -7 

Telephone number:

 _(____)__________________________________

Area code Telephone number

REFUSED........................................ -7

DON’T KNOW................................ -8

NOT APPLICABLE ..................-9

Cell phone:

 _(____)__________________________________

Area code Telephone number

REFUSED........................................ -7

DON’T KNOW................................ -8

NOT APPLICABLE ..................-9

Email address:

__________________________________

REFUSED........................................ -7

DON’T KNOW................................ -8

NOT APPLICABLE ..................-9

C.2. Please tell me the name, address, telephone number, and email address of a relative or close friend 

who does not live with you and who will always know how to contact you.

Name: 

First Name Last Name
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

Address: 

Number Street Apt. No.

City State Zip Code

REFUSED........................................ -7 

DON’T KNOW................................ -8 

Telephone number:

 _(____)__________________________________

Area code Telephone number

REFUSED........................................ -7 

DON’T KNOW................................ -8

NOT APPLICABLE ..................-9

Email address:

__________________________________

REFUSED........................................ -7

DON’T KNOW................................ -8

NOT APPLICABLE ..................-9

C.3. Thank you for your time today. Please do not hesitate to contact me at _________________ if you 

have questions about your service or cash payback requirements.
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

Version A, Sub-Section A: Program Office Initiates Contact with a Participant Via Email

Below is an introduction for Version A of the protocol that will be utilized when the program office 

initiates contact with participants via email. Note that the introduction has been modified to facilitate 

email contact. Email contact requires that the survey format will be modified slightly to facilitate self 

administration as identifying information such as name, home address, date of birth, and last 4 digits of 

the participant’s SSN should not be transmitted by email. Thus, these fields should not be included in 

email follow-up activities. The IE PD staff may need to contact the participant by phone to verify name, 

date of birth, and last 4 digits of the SSN. 

INTRODUCTION

Dear _________________ (INSERT GRANTEE INFORMATION) participant:

Hello. My name is __________________ of the U.S. Department of Education. I am writing on behalf 

of the Indian Education Professional Development program. I am writing because our records indicate 

you participated in this program through the __________________________ project (INSERT 

GRANTEE PROJECT NAME). As you may know, on-going contact between project participants and 

the Indian Education Professional Development program after exiting project training is a requirement of 

program participation. I am writing to collect some required information from you about your 

employment and educational status.
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

Participant Follow-Up Protocol 

Version B: Participant Initiates Contact with Program Office

Instructions to IE PD staff 

If a participant contacts the program office by telephone, proceed with the protocol below. If the 

participant contacts the program office by email, follow the instructions provided in Version B, subsection A. 

INTRODUCTION

Good (morning/afternoon/evening). My name is __________________ and I am happy to collect some 

information from you about your employment and educational status. 

To begin with, please provide me with your identifying information including first and last name, date of 

birth, and last 4 digits of your Social Security Number (SSN) so we can update our records accurately:

First name: 

Last name: 

Date of birth: 

Last 4 digits of SSN: 

Is this the first contact with Indian Education Professional Development program office that you have had 

since leaving the Professional Development program?

Yes .................................................. 1 GO TO CONTACT STATUS INSTRUCTION BOX

No .................................................... 2 GO TO CONTACT STATUS INSTRUCTION BOX

CONTACT STATUS INSTRUCTION BOX

CHECK HERE □IF THIS IS THE FIRST FOLLOW-UP CONTACT SINCE THE PARTICIPANT 

EXITED THE PROJECT AND USE “SINCE YOU EXITED THE INDIAN EDUCATION 

PROFESSIONAL DEVELOPMENT PROJECT” FOR THE TEXT WHERE NOTED IN THE 

QUESTIONS THROUGHOUT THE SURVEY.

OTHERWISE USE “SINCE OUR LAST CONTACT” FOR THE TEXT WHERE NOTED IN THE 

QUESTIONS. 

Paperwork 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 xxxx-xxxx. The 

time required by grantees to complete information on the participant protocol is estimated to average 30 minutes per participant semiannually, or 1 hour per participant per year. 
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

SECTION A: EDUCATION ENROLLMENT INFORMATION

A.1. Are you currently enrolled full time in a degree-granting program at a community college, college, 

or university?

Yes .................................................. 1 GO TO A.2

No .................................................... 2 SKIP TO A.4

A.2. Were you enrolled full time in a degree-granting program at any other community college, college, 

or university [since you exited the Indian Education Professional Development project/since our 

last contact]?

Yes .................................................. 1 

No .................................................... 2 

A.3. To be considered for deferment for your Indian Education Professional Development service 

payback requirement, you need to submit a written request to the program office. This request must 

include a copy of the letter of admission from the institution, the degree being sought, and the 

projected date of completion. If deferment is granted, you must submit a status report, showing 

verification of enrollment and status, from an academic advisor or other authorized representative at 

the institution of higher education in which you are enrolled. This status report is to be submitted 

after every grading period. Please send the written request to __________________ [YOUR 

NAME] at Indian Education Professional Development Grants Program, U.S. Department of 

Education, 400 Maryland Avenue, SW, Washington, DC 20202-6510. 

CHECK HERE □ AFTER READING STATEMENT AND SKIP TO B.1.

A.4. [Since you exited the Indian Education Professional Development project/Since our last contact,] 

were you ever enrolled full time in a degree-granting program at a community college, college, or 

university?

Yes .................................................. 1 GO TO A.5

No .................................................... 2 SKIP TO B.1
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

A.5. To be considered for deferment for your Indian Education Professional Development service 

payback requirement, you need to submit a written request to the program office. This request must 

include a copy of the letter of admission from the institution, the degree being sought, and the 

projected date of completion. If deferment is granted, you must submit a status report, showing 

verification of enrollment and status, from an academic advisor or other authorized representative at 

the institution of higher education in which you are enrolled. This status report is to be submitted 

after every grading period. Please send the written request to __________________ [YOUR 

NAME] at Indian Education Professional Development Grants Program, U.S. Department of 

Education, 400 Maryland Avenue, SW, Washington, DC 20202-6510. 

CHECK HERE □ AFTER READING STATEMENT AND CONTINUE WITH SECTION B.

SECTION B: EMPLOYMENT EXPERIENCE

B.1. Are you currently employed? 

Yes .................................................. 1 GO TO B.2

No .................................................... 2 SKIP TO B.10

B.2. Are you employed at a school or local educational agency (LEA)? 

Yes .................................................. 1 GO TO B.3

No .................................................... 2 SKIP TO B.10

B.3. Are you employed full or part time in this school or LEA?

Full time .......................................... 1 

Part time .......................................... 2 

B.4. What is the name and address of the school where you are currently employed? 

School name: __________________________________

School address: ________________________________

B.5. If applicable, what is the name and address of the LEA where you currently are employed? 

LEA name: ___________________________________

LEA address: __________________________________
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

READ: Please be advised that one of the requirements of your service payback agreement is to 

ensure that the Indian Education Professional Development program office receives verification 

of your employment in an approved LEA. We will send you an Employment Verification Form 

that should be given to your principal, if you are a teacher or vice principal, or an LEA 

representative, if you are a principal, to complete and submit to us. 

B.6. [Since you exited the Indian Education Professional Development project/Since our last contact,] 

were you employed at another school or LEA? 

Yes .................................................. 1 GO TO B.7

No .................................................... 2 SKIP TO C.1

B.7. What was/were the name(s) and address(es) of the school(s) where you were previously employed? 

School name: __________________________________

School address: ________________________________

REPEAT AS NECESSARY FOR ADDITIONAL SCHOOLS

B.8. If applicable, what was/were the name(s) and address(es) of the LEA(s) where you were previously 

employed? 

LEA name: ___________________________________

LEA address: __________________________________

REPEAT AS NECESSARY FOR ADDITIONAL LEAS

B.9 Were you employed full or part time in the school(s) or LEA(s)?

Full time .......................................... 1 

Part time .......................................... 2 

REPEAT AS NECESSARY FOR ADDITIONAL SCHOOLS OR LEAS

READ: If you were employed in an approved LEA for the service payback requirement, you may 

be able to use this employment to fulfill some or your entire service payback obligation. To do 

so, you must give an Employment Verification Form to the principal or LEA representative under 

whom you worked to verify the nature and duration of your employment. We will send you the 

Employment Verification Form that should forward to the appropriate individual to complete and 

submit to us. 

SKIP TO C.1
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

B.10. [Since you exited the Indian Education Professional Development project/Since our last contact,] 

were you ever employed at a school or LEA ?

Yes .................................................. 1 GO TO B.11

No .................................................... 2 SKIP TO C.1

B.11. What was/were the name(s) and address(es) of the school(s) or LEA(s) where you were previously 

employed? 

School name: __________________________________

School address: ________________________________

LEA name: ___________________________________

LEA address: __________________________________

REPEAT AS NECESSARY FOR ADDITIONAL SCHOOLS OR LEAS

B.12 Were you employed full or part time in the school(s) or LEA(s)?

Full time .......................................... 1 

Part time .......................................... 2 

REPEAT AS NECESSARY FOR ADDITIONAL SCHOOLS OR LEAS

READ: If you were employed in an approved LEA for the service payback requirement, you may 

be able to use this employment to fulfill some or your entire service payback obligation. To do 

so, you must give an Employment Verification Form to the principal or LEA representative under 

whom you worked to verify the nature and duration of your employment. We will send you the 

Employment Verification Form that should forward to the appropriate individual to complete and 

submit to us. 

CONTINUE WITH SECTION C.
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

SECTION C: FOLLOW-UP CONTACT INFORMATION

C.1. As part of the service payback requirement, we will need to hear from you again in 6 months. We 

would like to update your contact information for our files. Please tell me you current address, 

telephone number, and email address:

Address: 

Number Street Apt. No.

City State Zip Code

REFUSED........................................ -7 

Telephone number:

 _(____)__________________________________

Area code Telephone number

REFUSED........................................ -7

DON’T KNOW................................ -8

NOT APPLICABLE ..................-9

Cell phone:

 _(____)__________________________________

Area code Telephone number

REFUSED........................................ -7

DON’T KNOW................................ -8

NOT APPLICABLE ..................-9

Email address:

__________________________________

REFUSED........................................ -7

DON’T KNOW................................ -8

NOT APPLICABLE ..................-9
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

C.2. Please tell me the name, address, telephone number, and email address of a relative or close friend 

who does not live with you and who will always know how to contact you.

Name: 

First Name Last Name

Address: 

Number Street Apt. No.

City State Zip Code

REFUSED........................................ -7 

DON’T KNOW................................ -8 

Telephone number:

 _(____)__________________________________

Area code Telephone number

REFUSED........................................ -7 

DON’T KNOW................................ -8

NOT APPLICABLE ..................-9

Email address:

__________________________________

REFUSED........................................ -7

DON’T KNOW................................ -8

NOT APPLICABLE ..................-9

C.3. Thank you for your time today. Please do not hesitate to contact me at _________________ if you 

have questions about your service or cash payback requirements.

Version B, Sub-Section A: Participant Initiates Contact Via Email

If the participant initiates contact with the program office by email, the program office has the 

opportunity to check the participant’s records on the following prior to responding to the email:

 The grantee’s project name;

 Whether this contact will be the first contact between the participant and the IE PD staff since the 

participant exiting project training; and 

With this information, the IE PD program staff can pre-fill the grantee’s project name and contact status 

instruction box of the Version B protocol if relevant. For all email replies, the IE PD staff should replace 

the introduction of the Version B protocol with the introduction below. Note that the introduction has 
OMB Reference Number: 1810-0698

OMB Expiration Date: 3/31/1X

been modified to facilitate email contact. Email contact requires that the survey format will be modified 

slightly to facilitate self administration as identifying information such as name, home address, date of 

birth, and last 4 digits of the participant’s SSN should not be transmitted by email. Thus, these fields 

should not be included in email follow up activities. The IE PD staff may need to contact the participant 

by phone to verify name and date of birth. 

INTRODUCTION

Dear _________________ (INSERT GRANTEE INFORMATION) participant:

Hello, my name is __________________ and I am happy to collect some information from you about 

your employment and educational status.