1 **OMB No. 1840 -**  **0753 Expiration Date:**  **XX/XX/XXXX** 

## Teacher Quality Enhancement Program **Title II, Higher Education Act Verification of Teaching Obligation**  The individual identified on page two is a new teacher employed by your school district. He or she re ceived a scholarship provided under the Teacher Quality Enhancement Program (TQE) to attend a teacher preparation program. As a condition of that scholarship, within six months of completing the program, the individual must begin teaching in a high - need s chool, as that term is defined in Section II, Part C of this form. The individual must continue teaching in a high - need school for a period equivalent to the length of time for which he or she received the scholarship. The U. S. Department of Education ( Department) needs the information identified in this document so that it can confirm that the individual has fulfilled this service obligation. For Sections I and II, we ask that you furnish this information by October 1 for individuals who begin teachi ng at the beginning of the school year, and within seven days of receipt for individuals who begin teaching at other times. The Department needs to obtain the information only once during the school year. For Section III, we ask that you furnish the info rmation on the teacher’s regular school -year employment in your school district (Parts A1 , A2, A3, A4, and Part B) within seven days of the end of the school year. If the individual teaches during the summer (or intersession period if the school district operates a year- round program) in a high - need school, we ask that you furnish the information in Part A 5 within seven days of the end of the summer session. Please also include any changes in the name, address, telephone number, fax number, or e - mail address of the school district’s reporting official that was previously provided in Section I. Please mail this completed form to:

U.S. Department of Education Office of Postsecondary Education Teacher Quality Enhancement Program 1990 K Street N.W., 7th fl oor Washington, DC 20006 - 8526 Thank you for your assistance.2



## I. **Scholarship Recipient / Teacher Information** Name: ________________________________________________

________ ____________

_ _______ Permanent Address: _______________________________________

_ ________ ________ _ ________ City , State, Zip Code: _____________________________________

________ ___________________ Permanent Telephone Number: ____________________________

________ ____________

_ _______ Permanent E - Mail __________________________________

_______ Alternate Address: _________________________________________ City, State, Zip Code: _________________________________________ Alternate Telephone Number: _________________________________________ Alternate E - Mail: _____________________________

____________ 

### Social Security Number: _________________________________

_________

___________________ Date of Birth: _____________________________________________

_________

________________ Institution that Provided your Scholarship Assistance: ___________

_____ __________

_____________ 

## II. **School District / School Information Part A.**  School District: ___________________________________________________

________ _________ Address: ____________________________________________________

________ _____________ Name of District Official Providing this Information: _________________

_______ ________________ Title of District Official Providing this Information: ___________________

_______ _______________ Telephone Number: __________________________________

_______ ___ _____________ Fax Number: _________

___ ____ _ ________ E - Mail: _________

____ __________________

_________________________________ has been employed by the school district as a teacher

(Name of Teacher) 

### at ____________________________________________

_____ ____________________________ ( School Name)3



###  since the beginning of this school year /  beginning ____ weeks after the school year began. Teaching Start Date: _________________________________________ 

## Part B. During the current academic year, he/she will be teaching at this school  full - time  part- time If part- time, he/she has a teaching schedule that is _____% of the district’s full - time teachers. 

## Part C. To retain his/her financial assistance as a scholarship, _________________

________________________ (School Name) 

### must be a “high - need school “ as the term is used in the Teacher Quality Enhancement Grant Programs. Please check at least one box that applies to the school: 1a.  40 percent or more of the enrolled stud ents are eligible for free and reduced lunch subsides; or b.  The school is otherwise eligible, without need of a waiver, to operate as a schoolwide program under Title I of the Elementary and Secondary Education Act. 2.  34 percent or more of the sc hool’s academic classroom teachers do not have a major, minor, or significant course work in their main assignment field. 3.  34 percent or more of the main assignment faculty in two of the core - subject departments do not have a major, minor or signific ant work in their main assigned field. 4.  The school has had an attrition rate among classroom teachers of 15 percent or more over the last three school years. **NOTE: If none of these categories applies to the school in which the individual is teachi ng, please**  **notify the individual immediately. He or she is at risk of becoming legally responsible for repayment of the full amount of his/her scholarship.**  Questions / Comments: _________________________________

_____ _________________________

__________

___________________________________________________ _____ ________________

_______________________________________________________________ _____ ______________ I certify that the information contained in this document is correct. *4



### ______________________ ____ ____ ___________ _____________________________ **Signature of School District Official Date** 

_____________________________ ____ ________ _____________ ___________

_____ **Name of School District Official Title**  *** Note: Please provide original sig nature. Do**  **not use rubber stamp.** 5



## III. **Confirmation of School -** **Year /Summer Employment** (To be completed within seven days of the end of the school year or summer / intersession period. **Please submit this to the U.S. Department of Education along with the pr** **eviously completed SECTIONS I and II.)**  

## Part A.

_______________________________________________

(Name of Teacher) 

### 1.  Continued to teach at :

_________________________ _______________

___ __ __________ (School Name) 

### for the remainder of the school yea r in the same full - time or part- time capacity as reported earlier this year. 2.  Became a teacher at another school, _______________________________

__ __________, (School Name) 

### beginning _________________ and taught there in the same full - time or part- time capacity as (Date) 

### previously reported. This is a high - need school because it meets the criterion in Box ____ in Section II.C of this document. 3.  Teaching End Date:

_________________________________________ 

### 4.  Number of semeste rs Scholarship Recipient/Teacher taught:

____________________________ 

### (Include summer teaching assignments in determining total semesters taught). 5.  **____** Taught this summer / intersession period at:

______________________________________________ ____. (School Name) 

### This is a high - need school because it meets the criterion in Box __ in Part II . C of this document. **The individual taught at this school from ______________________ to ____________________.** (Date) (Date) 

## Part B. If neither 1 nor 2 of Part A is true. Please explain the change of the individual’s employment status from what the school district reported in Section II. If applicable, please also provide the date on which the individual no longer was empl oyed by the school district or worked in a high - need school.

_______________________________________________________________________ ___ ______6



### _________________________________________________________________ ___ ____________

____________________________ ____________________________________ ___ _____________ Questions / Comments: _________________________________

__ _________________________

______________________________________________________ __ _______________________

______________________________________ ___________________

__ ____________________ I certify that information contained in this document concerning __________

_______ ___________ is correct. (Name of Teacher)



### __________________________________ **____ ___**  **________ _____**  **_ __**  **_________ Signature of Sch**  **ool District Official *** **Date**

**_______________________________ ____**  **______ __________**  **_______ ________**  **Name of School District Official Title**  ***** 

### Original signature required. Do not use stamp.7 

### Privacy Act Notice The Privacy Act of 1974 (5 U.S.C. 5 52a) requires that the following notice be provided to you. T he authority for collecting the requested information from and about you is Title II, Section 204(e) of the Higher Education Act of 1 965, as amended by

the 1998 Higher Education Amendments, and 31 U.S.C. Chapter 37. W e request yo ur Social Security Number (SSN) under this authority in order to accurately track your records and to differentiate your teaching and financial obligation from other program participants who may have the same name as yo u . Y ou are advised that yo ur participation in the Teacher Quality Enhancement Grants scholarship program is voluntary and that giving us your SSN is voluntary, but you must provide the requested information, including yo ur SSN, to participate. T he information will be used to ensure that recipients of scholarships provided with funds under Title II of the Higher Education Act subsequently: (1) complete a teacher education program and teach in a high - need school of a high - need local educational agency for a period of time equivalent to the period for which the recipient received scholarship assistance; or (2) repay the amount of the scholarship. The information in yo ur records may be disclosed to third parties as authorized under routine uses in the appropriate systems of records, either on a case -by - case basis, or, if the Department has com plied with the computer matching requirements of the Privacy Act, under a computer matching agreement. The routine uses of this information include sending the information, in the event of litigation, to the Department of Justice (DOJ), a court, adjudicative body , counsel, party, or witness if the disclosure is relevant and necessary to the litigation. I f this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. W e may also send this information to law e nforcement agencies if the information is relevant to any enforcement, regulatory, investigative, or prosecutorial responsibility within the receiving entity’s jurisdiction. We may send information to the Department of

T reasury and to credit agencies to verify the identity and location of the debtor and to the Department of Treasury, collection agencies, and em ployers of the scholarship recipient in order to service or collect on the debt. We may send information to members of Congress if yo u ask them to help yo u with questions related to this Program . In circumstances involving em ployment com

plaints, grievances, or disciplinary

a ctions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, wemay disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. If necessary for the Departme nt to obtain advice from the DOJ, we c an disclose information to the DOJ. W e may disclose information to the DOJ or the Office of Management and Budget (OMB) to help us determine whether the Freedom of Information Act requires the disclosure of particul ar records. W e can disclose records to contractors if we contract with an entity to perform functions that require the disclosure of the records. D isclosures may also be made to qualified researchers under Privacy Ac t safeguards. F inally, disclosures may be made to OMB as necessary under the requirements of the Credit Reform Act. Y ou must provide all of the information requested in order to have your request for tuition reimbursement processed. 

### P **ublic Burden Statement**  According to the Paperwork Reduc tion 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 3 0 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 a benefit . The authority

for collecting the requested information from and about you is Title II, Section 204(e) of the Higher Education Act of 1965, as amended b y the 1998 Higher Education Amendments, and 31 U.S.C. Chapter 37. We request your Social Security Number (SSN) under this authority in order to accurately track your records and to differentiate your teaching and financial obligation from other program participants who may have the same name as you. You are advised that your participation in the Teacher Quality Enhancement8



### Grants scholarship program is voluntary and that giving us your SSN is voluntary , but you must provide the requested information, including your SSN, to participate. 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 e - mail ICDocketMgr@ed.gov and reference the OMB Control Number 1840 - 0753. Note: Please do not return the completed Verification of Teaching Obligation to this address.