**Indian Education Professional Development Grants Program**  **U.S. Department of Education Employment Verification Form** 
**Introduction** The Indian Education Professional Development (IE PD) 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 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 IEPD grantees, participants and school principals or local educational agency (LEA) representatives. Data collection also will be used to help ensure participants are fulfilling program requirements with regard to service/cash payback. This appendix contains the protocol for verifying employment of IE PD program participants after exiting project training. P articipants who become employed as teachers or vice principals must receive employment verification from their school principal. P articipants who become employed as principals must receive employment verification from an LEA representative. The participant is responsible for ensuring the appropriate person receives this Employment Verification Form, completes the form and submits the form to OIE. Below are instructions for IE PD staff, a letter from IE PD participants to principals/LEA representatives, and the employment form to be completed by principals/LEA representatives.
**Instructions to IE PD staff** The IE PD program staff will learn where participants are employed through the information collected in the Participant Follow

-Up Protocol. IE PD program office staff will determine if the LEA of employment reported by the participant meets IE PD service payback criteria of enrolling at least 5 percent American Indian/Alaska Native students (i.e., an approved LEA). 1 If the LEA of em

ployment enrolls at least 5 percent American Indian/Alaska Native students, IE PD staff will send the participant the Employment Verification Form. P articipants who achieve employment as teachers or vice principals should provide this form to their school principal for completion and submission to OIE. P articipants who achieve employment as principals should provide this form to their LEA representative for completion and submission to OIE.

1 Service in a private school with a minimum American Indian and Alaska Native enrollment of 5 percent also counts as an approved setting.If the LEA of employment does not enroll the required minimum percentage of American Indian/Alaska

Native students, the participant is not in compliance with the service payback agreement. In this circumstance, the IE PD staff does not need to send the Employment Verification Form to the participant. Instead, the IE PD staff should contact the participant about non-compliance of the service payback agreement. If a participant is working in an approved LEA, the participant must initiate the employment verification process with his or her principal or LEA representative within 6 months of a participant exiting project services and every 6 months thereafter until participant ends service obligation. Thus, follow

-up data collection will be on

-going and could occur throughout the year depending on when a participant exits the project. If a participant has been employed at multiple schools and/or in multiple positions at schools since existing project services, the participant must ensure employment verification is received from each principal or LEA representative.**Employment Verification Form Letter from Participants to Principals/LEA Representatives**  (INSERT DATE) (INSERT PRINCIPAL OR LEA REPRSENTATIVE CONTACT NAME) (INSERT SCHOOL OR LEA CONTACT ADDRESS) (INSERT SCHOOL OR LEA CITY, STATE AND ZIP) Dear (INSERT PRINCIPAL OR LEA REPRESENTATIVE CONTACT NAME): This letter requests verification of my em ployment. Iam submitting this request to you because I was a participant in the U.S. Department of Education’s (ED’s) Indian Education Professional Development (IE PD) program, which has a service payback requirement. ED requires information on my position (teacher or administrator), employment duration, and for teachers, information on subject(s) taught and Highly Qualified Teacher status. ED’s Office of Indian Education will use this information to determine if I am meeting my service payback requirement and to report on program performance measures. ED needs you to complete the enclosed IE PD Employment Verification Form and submit it to the Office of Indian Education **within 2**  **weeks of**  **receipt**
. Completed forms are to be returned to Ms. Lana Shaughnessy, Office of Indian Education, Indian Education Professional Development Program, U.S. Department of Education, 400 Maryland Avenue, SW, Washington, DC 20202

-6510. Completed forms are to be returned by the U.S. Postal Service; please ensure the envelope is securely sealed. Do NOT send this form via facsimile or email due to the personally

-identifiable nature of the data. If you should have any questions regarding completion or submission of the IE PD Employment Verification Form or any aspect of this request, please do not hesitate to contact Ms. Lana Shaughnessy of the Office of Indian Education at (202) 205

-2528
. Please note that I am

required to verify my em ployment every 6 months for as long as I am employed in this school and completing my service requirement. Thank you in advance for your cooperation. Sincerely, (PARTICIPANT’S NAME)OMB Reference Number:

OMB Expiration Date: **IE PD Employment Ver ification Form** 
**Instructions**
**Part 1:**  For “Update date” enter today’s date. Please provide the requested contact and identifying information for the project participant seeking employment verification. We will use this information to match with Office of Indian Education program records. **Part 2:**  Please provide the em ployment information requested in each cell. Note that if the participant is employed in multiple positions in your school, please use a separate line to describe each position. In the example provided on the form, John Doe obtained employment in Des Moines Elementary as both teacher and administrator; thus John Doe’s information is contained on two lines, one for his teaching position and one for his administrator’s position. Please enter the local educational agency name (LEA) and LEA NCES ID num ber. The LEA NCES ID number can be found at http://nces.ed.gov/ccd/districtsearch/ . This is not applicable for private schools. Print and sign your name. **Please complete**  **and sign**  **this fo** **rm within**  **2 weeks**  **of r** **eceipt**
. When you have completed the Employment Verification Form, please submit a hard copy to Ms. Lana Shaughnessy, Office of Indian Education, Indian Education Professional Development Prog ram, U.S. Department of Education, 400 Maryland Avenue, SW, Washington, DC 20202

-6510. Do NOT send this form via facsimile or email due to the personally

-identifiable nature of the data. All data collection activities will be conducted in full com pliance 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 subj ects as contained in ED regulations. **Public Burden Statem ent:**  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 1 hour 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 (Elementar y 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)). S end 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 Num ber 1810
- 0698 . Note: Please do not return the completed Em

ployment Verification form to this address. **IE PD Employment Verification Form (continued) Part 1: Participant Contact and Identif**  **ying Information** Update date Last name First name Current address Date of birth Last 4 digits of theOMB Reference Number:

OMB Expiration Date: (including City & State) Social Security Number 12/15/08 Doe, John John 100 Avenue C, Des Moines IA 01

- 01

- 1970 6789 12/15/08 Doe, John John 100 Avenue C , Des Moines IA 01

- 01

- 1970 6789

**Part 2: Employment Information**

**School name**  **Position Type**

**Position start date**  **Position**

**end date*** **Full -** **time**

**or part****** **time employ** **** **ment status If** 

**administrator position If**  **teacher position**

**Administrato r,**  **Teacher, Other If** 

**other position,**  **please specify Type (principal,**  **vice principal, other)**  **If**

**other type, please specify**  **Subject**

**taught Is Highly** 

**Qualified for this**  **subject? 1**  **(yes or no)** Des Moines Elementary Administrator 08/20/08 Still employed Full time Vice principal Des Moines Elementary Teacher 08/01/07 08/19/08 Full time 3

- 5 all subjects yes

*I f the individual still is employed in this position, please enter "still employed" in this cell. 1 The federal definition of Highly Qualified can be found in the Elementary and Secondary Education Act, reauthorized as No Child Left Behind, Section 9101 (23): http://www.ed.gov/policy/elsec/leg/esea02/pg1 07.html **IE PD Employment Verification Form (continued)**OMB Reference Number:

OMB Expiration Date: Local Educational Agency Name:

________________________________ __ Local Education Agency NCES ID number:

________________________ Name of individual completing form:

_______________________________ Signature of individual completing form:

__________________________ (please print)