U.S. Department of Education

Indian Education Professional Development Grants Program:

GPRA and Service Payback Data Collection

Appendix E

Office of Management and Budget

Clearance Package Supporting Statement

And Data Collection Instrument

June 29, 2009
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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 IE PD 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. Participants who become employed as teachers or vice principals must receive 

employment verification from their school principal. Participants 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 employment enrolls at least 5 percent American Indian/Alaska Native students, IE PD staff 

will send the participant the Employment Verification Form. Participants who achieve employment as 

teachers or vice principals should provide this form to their school principal for completion and 

submission to OIE. Participants 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. 
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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.
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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 employment. I am 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 employment 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:

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IE PD Employment Verification 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 employment 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 number. 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 form within 2 weeks of receipt. 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 Program, 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.

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 principals/LEA representatives to verify employment is estimated to average 1 hour per participant semiannually, or 2 hours per participant per year. 
OMB Reference Number:

OMB Expiration Date:

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IE PD Employment Verification Form (continued)

Part 1: Participant Contact and Identifying Information

Update date Last name First name

Current address 

(including City & 

State) Date of birth

Last 4 digits of the 

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 parttime 

employment status

If administrator position If teacher position

Administrator, 

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

*If 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/pg107.html
OMB Reference Number:

OMB Expiration Date:

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IE PD Employment Verification Form (continued)

Local Educational Agency Name: __________________________________ Local Education Agency NCES ID number: ________________________

Name of individual completing form: _______________________________ Signature of individual completing form: __________________________

(please print)