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 p articipant 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. D ata 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 Ja ne 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 IEPD 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 Instr** **uctions 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. F or 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 staf f will use the alternate contact’s telephone number to contact someone whom the participant indicated would “always knowOMB 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 Statem ent:**  According to the Paperwork Reduction Act of 1 995, no persons are required to respond to a collection of information unle ss 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 B ehind 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 18 10 -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. Iam calling on behalf of the Indian Education Professional Development program. Iam 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. Iam 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**  **T HE**  **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 “SI

NCE OUR LAST CONTACT” FOR THE TEXT WHERE NOTED IN THE QUESTIONS. 

### PRE-FILL USING DATA FROM MOST RECENT SAPROMB 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 Profes sional 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 o f 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 D evelopment 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 ADDIT IONAL 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 ADDIT IONAL 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 ADDIT IONAL SCHOOLS OR LEASOMB 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 ADDIT IONAL 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 ADDIT IONAL 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 m ust 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 NameOMB 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. Iam writing on behalf of the Indian Education Professional Development program. Iam 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. Iam 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, sub section 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 S TATUS 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 Pa

perwork Reduction Act of 1995 , no persons are required to respond to a collection of inf ormation 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. Depa rtment 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.1OMB 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 o f 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 t

he name(s) and address(es) of the school(s) where you were previously employed? School name:

________________________________ __ School address:

________________________________ REPEAT AS NECESSARY FOR ADDIT IONAL 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 ADDIT IONAL 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 ADDIT IONAL 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.1OMB Reference Number: 1810 -0698

OMB Expiration Date: 3/31/1X B.10. [S ince 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 ADDIT IONAL 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 ADDIT IONAL 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 com plete 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 .................. -9OMB 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 hasOMB 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 addres s, 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.