# Personnel Development Program Data

**Collection System: Employ**  **ment Verification**  **Form (Completed by** 

**Employ er)**  OM B Control Number: 1820 - 0686 Ex piration: xx/ xx/xxxx **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 10 mi nutes per response, including time for reviewing instruc tions, 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 required to obtain or retain benefit ( Individuals with Disabilities Education Act ). 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 em a il ICDocketMgr@ed.gov and reference the OMB Control Number 1820 - 0686 . Note: Please do not return the completed em ploy ment verification form to this address.OM B Control Number: 1820 - 0686 Expiration: XX/XX/XXXX 

### Rules of Behavior for Department of Education **- Sponsored Website**  The Personnel Development Program Data Collection System (DCS) is an online data collection system designed to facilitate administration of the program by the Office of Special Education Programs at the U
. S

. Department of Education

. Thi s sy stem collects employ me nt and contact information from participating scholar/obligees to verify the fulfillment of their serv ice obligation and assess program performance. Verif yi ng service obligation requires collecting personally identifying informati on 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 regulations printed in the Federal Register Vol ume 71 No. 107 Jun e 5, 2006 , and the Government Performance and Results Act of 1993, section 4. Users of the DCS mu st agree to certain conditions and agree to act to insure the accuracy and confidentiality of the information stored by the DCS

. Em ployers using this system ag ree to:

 Maintain the confidentiality of requested employ me nt information about scholars/obligees ;  Maintain control of secure links by adhering to workplace security safeguards; and  Verif y scholar/obligee employ me nt within 30 days of the annual notificatio n e - ma il from DCS. 

## □ **I agree to the terms.**OM B Control Number: 1820 - 0686 Expiration: XX/XX/XXXX **Employment Verification Page 1** We lcom e to the Personnel Development Program Data Collection System (DCS ) . The obligee listed below accepted a scholarship from a grant awarded to an Institution of Higher Educa tion (IHE) by the U
. S

. Department of Education , Office of Special Education Programs (OSEP). These scholarships include a service obligation requirement of two ( 2 ) years of eligible employ me nt for each year of IHE support. Obligees are required to provide DCS with annual updates about their employ ment in order for DCS to track the fulfillment of their service obligation. Additional information about DCS and the service obligation is available on the DCS We b site at http://serviceobligation.ed.gov

. Please take a moment to verify the accuracy or to correct any inaccuracies of the information provided by the obligee. W e anticipate that the survey will take no longer than 10 minutes to complete. Your session will timeout after 30 minutes of inactivity and the information entered will not be saved. Do NOT use your internet browser's back button during this process. Thank you for taking the time to provide this information

. **Employee Name:** * Required fields necessa ry to submit a record. **Empl oy**  **er Information** 

*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/XX/XXXX **Supervisor Information**  Please provide the name of a supervisor at thi s job who can verify this employ ment information.

* First: * Last:



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



### ___________________________ __________________________ Cit y: State: Zip Code:



### _______________

_ ___________ ______ -

____ Phone: Mobile Phone :



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

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



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

**_________________ ___________________** Fax: TT Y: _____________________ (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 employ me nt information.

***** **First:** ***** **Last:**



### ___________________________ __________________________ **Human Resource Business Manager’s A ddress:**  **Ad dress Line 1:**  **Ad dress Line 2:** 



### ___________________________ __________________________ **City: State: Zip Co de:** 



### ________________ **___________ ______ -**  **____ Phone: Mobile Phone:** 



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

***** **E -**  **mail:** ***** **Verify E -**  **mail:**



### _________________ ________________ **Alternative E -**  **mail A ddress:**  **Verify A lt. E**  **- mail:** 

**_________________ ___________________ Fax: TTY:** OM B Control Number: 1820 - 0686 Expiration: XX/XX/XXXX **_____________________ (xxx -**  **xxx -**  **xxxx) __ ___________________ (xxx**  **- xxx**  **** **xxxx)**OM B Control Number: 1820 - 0686 Expiration: XX/XX/XXXX **Employment Verification Page 2 .**  **Please review the information below.** If y ou AGREE with all of the obligee’s responses, click the Proceed button at the bottom of the page. If y ou DISAGREE with the obligee's respons e to a particular question, please check the box beside the question and describe the reason for your disagreement in the box provided. Once y ou have completed all questions, please click the “Proceed” button at the bottom of the page. An Employ me nt Verifi cation Report will be sent to the obligee, and he or she will have the opportunity to accept yo ur changes or revise them and resubmit for yo ur verification. **Employee Name: Employee Position Information**  Questions marked in **blue** do not affect the oblig ee's service obligation fulfillment status. These questions are for measuring program performance at OSEP

. 1. * Wh en did this job begin? 1 (mm/dd/yyyy) **Disagree □**  Obligee Response : If y ou disagree, please explain:

2. * Is the oblige e currently employed in this position? **Disagree □**  O bligee Response: If y ou disagree, please explain:

3. * Is this full time or part time employ me nt? **Disagree □**  Obli ge e Response: If y ou disagree, please explain:

1 PLEASE NOTE: The start date indicated in the employment record may not reflect the actual start date of employme nt. As per program regulations, scholars/obligees may begin work in eligible employment following the completion of one academic year of training. Therefore, the DCS only allows for start dates of an employment position after the completion of one academic year of training. Please verify that the scholar/obligee was employed during the dates listed above.OM B Control Number: 1820 - 0686 Expiration: XX/XX/XXXX 4. * Wh ich of the following best describes the position? * Disagree □ Obligee Response : 

### o Special education t eacher o Early intervention , early childhood, or early childhood service provid er 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 suppo rtive service provider in a non - school setting (e.g., child find services ) o Administrator/coordinator / s upervisor (including the capacity of a principal) o Instructional s pecialist o Higher education (e.g., faculty, research assistant, practicum coordinator) o Ot her, within education (please specify

____________________________ ) If y ou disagree, please explain:OM B Control Number: 1820 - 0686 Expiration: XX/XX/XXXX Please review Questions 5 and 6 if the scholar selected one of the following answers for Question 4:  Special education teacher  Early intervention, early childhood, or early childhood service provider  Paraprofessional/aid 5. Describe the percentage of time spent teaching or serving special education students in this position. **Disagree □**  Obligee Response **:** o 50 % or less o At least 51% If y ou disagree, please explain:
6. Describe the percentage of special education students taught or served in this position. **Disagree □**  Obligee Response **:** o 50 % or less o At least 51% If y ou disagree, please explain: 7. * Is the obligee "highly qualified/qualified/fully certified" for this position under Individuals with Disabilities Education Act (IDEA) and has not had certification or licensure requirements waived on an emerg ency, temporary or provisional basis ? "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 posi tion. **2 Disagree**  **□** Obligee Answer: If y ou disagree, please explain:

This question is confidential and will not be shared with the obligee
. 8. At this time, the oblige is rated on the (State, District, or School) performance appraisal system as **:**
o Effective o Less than effective o Ineffective o Not rated for this position

2 If the position is an elementary or secondary general education/special education teacher, the employee can be "highly qualif ied"; if the position is ge neral education/special education paraprofessional/aide or early intervention, early childhood or preschool paraprofessional/aide, the employee can be "qualified"; or if the position is administrator/coordinator, for related or suppo rtive services in a sch ool setting, or for teacher, related services, or supportive services in early intervention, early childhood, the employee ca n be "fully certified .”