Participant Training and Employment Information Form

OMB Control Number: 1810-0698

Expiration: 4/30/2016

Indian Education Professional Development

Data Collection System

Participant Training Information and Employment Reporting Form

OMB Control Number: 1810-0698

Expiration: 4/30/2016

OMB Paperwork Reduction 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 15 minutes per participant, 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 mandatory per section 7122 of the Elementary and Secondary Education Act of 1965, as amended, and its corresponding regulations, 34 CFR Part 263, Subpart A. 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 1810-0698. Note: Please do not return the completed Participant Record Form to this address.

Rules of Behavior for Department of Education-Sponsored Website

The Indian Education Professional Development (IEPD) Data Collection System (DCS) is an online data collection system designed to facilitate administration of the IEPD Program. This system collects employment and contact information from participants to verify the fulfillment of their payback agreements. Verifying payback requires collecting personally identifying information from grantees, participants, and employers. This data collection has been authorized by section 7122 of the Elementary and Secondary Education Act of 1965, as amended, and its corresponding regulations, 34 CFR Part 263, Subpart A.

Users of the DCS must agree to certain conditions and agree to act to insure the accuracy and confidentiality of the information stored by the DCS.

Violation of this policy will result in suspension of participant access to the DCS.

Participants using this system agree to:

• Maintain requested contact and employment information, and

• Maintain their DCS accounts by:

• Protecting account login names and passwords;

• Submitting accurate information for current address, phone number, email address, employment status and employer information; and

• Using the DCS only to access their own information;

By agreeing to these Rules of Behavior, participants agree to maintain the confidentiality of this information.

□ I agree to the terms.

Participant Training Information and

Employment Reporting Form

Instructions

Participant Main Menu

The information contained in this record was added by the Institution of Higher Education (IHE) at which you received your funded training. You are required to provide DCC with up-to-date contact information. To edit the information below, click on the "Edit My Information" link. To change your password, click on the "Change My Password" link. For security reasons you must contact DCC at 1-888-884-7110 or paybackobligations@ed.gov to change your name and Social Security Number.

You will be logged out of the system after 30 minutes of inactivity. A warning message will appear after 25 minutes of inactivity.

[ALL DATA IN SECTIONS A THROUGH D WILL BE PRE-FILLED BASED ON IHE RESPONSES IN THE PARTICIPANT RECORD FORM. PARTICIPANTS WILL ONLY NEED TO UPDATE INFORMATION THAT IS INCORRECT OR HAS CHANGED.]

A. Identifying Information
*First Name			Middle Name		*Last Name
Maiden Name, if applicable:
*Social Security Number (last 4)
*Date of Birth
*Primary E-mail Address
*Verify Primary E-mail Address
Alternative E-mail Address
Verify Alternative E-mail Address

B. Contact Information
Primary Address
*Address
*City		*State		*Zip Code
*Home Phone		Cell Phone
Secondary Address
Address
City		State		Zip Code
Other Phone		Fax

C. Alternate Contact1 Information

First Name

Last Name

E-mail Address

Verify Primary E-mail Address

Address

City

State

Zip Code

Home Phone

Other Phone

Fax _____

Please review and verify the information in Sections A, B, and C. Check the box below if there have been no changes in the last six months.

□ I have reviewed the information in Sections A, B, and C and it is still current.

D. Training and Service Payback Details

Please certify that the information provided by your Institution of Higher Education (IHE) is correct. If any of the items do not match your records, please contact your IHE. We also encourage you to contact DCC at 1-888-884-7110 or paybackobligations@ed.gov so that a ticket can be created concerning this matter. Your IHE will have to contact DCC to edit your record.

[ALL DATA IN SECTION D, EXCEPT THE LAST ITEM “VERIFY SERVICE PAYBACK DETAILS” WILL BE PRE-FILLED BASED ON IHE RESPONSES IN THE PARTICIPANT RECORD FORM.]

Training Program: [PRE-FILLED]

IHE

Project Title

Grant Number

Exit/Completion Date

Date Record Created by IHE

Date of Last IHE Update

EDUCATION INFORMATION

1. Check the degree(s) or certificate(s) or endorsement(s) you held when you entered this grant-supported training:

[Display of the item(s) selected by the IHE from the list below:

 □  High school diploma or equivalency
 □  Associate’s Degree
 □  Bachelor's Degree
 □  Master's Degree
 □  Educational Specialist
 □  Doctoral Degree
 □  Postdoctoral Degree
 □  State or Professional Credential/Certificate
 □ State-issued Endorsement
 □  Grantee-issued Endorsement]

2. Check the degree(s) or certificate(s) or endorsement(s) you received as a result of completing this grant-supported training:

[Display of the item(s) selected by the IHE from the list below:

 □  Associate’s Degree
 □  Bachelor's Degree
 □  Master's Degree
 □  Educational Specialist
 □  Doctoral Degree
 □  Postdoctoral Degree
 □  State or Professional Credential/Certificate
 □ State-issued Endorsement
 □  Grantee-issued Endorsement]

PROGRAM INFORMATION

1. Select the major field of study associated with your degree:

[Display of the item(s) selected by the IHE from the list below:

General Education

 □  Administration
 □  Elementary Education

 □  Secondary Education

 □  Social Work
 □  School or Educational Psychology

 □  Special Education

Subject Area

 □  Arts and Music

 □  Bilingual or English as a Second Language

 □  Early Childhood Education

 □  English or Language Arts

 □  Language Education (Native/Heritage/World Language)

 □  Health or Physical Education

 □  Mathematics or Computer Science

 □  Natural Sciences

 □  Social Sciences

 □  Career or Technical Education

 □  Other (please specify) __________]

2. Select the area of certification you attained after project training:

[Display of the item(s) selected by the IHE from the list below:

General Education

 □  Administration
 □  Elementary Education

 □  Secondary Education

 □  Social Work
 □  School or Educational Psychology

 □  Special Education

Subject Area

 □  Arts and Music

 □  Bilingual or English as a Second Language

 □  Early Childhood Education

 □  English or Language Arts

 □  Language Education (Native/Heritage/World Language)

 □  Health or Physical Education

 □  Mathematics or Computer Science

 □  Natural Sciences

 □  Social Sciences

 □  Career or Technical Education

 □  Other (please specify) __________

TRAINING PROGRAM EXIT/COMPLETION INFORMATION

[Display of the item selected by the IHE from the list below:

○ I am still enrolled in my program of study.

○ I am taking a leave of absence. (a leave of absence must be pre-approved by your project director, cannot exceed 1 year, and does not extend the availability of funds when the project ends)

○ I am on active military deployment.

○ I have completed my program of study.

○ I have exited the training program without completing my program of study.]

SERVICE PAYBACK INFORMATION:

1. Total number of months you were enrolled in training as of <INSERT DATE>:__________

2. Total funding amount received as of <INSERT DATE>:

Type of Expense	Cost ($)
Tuition, Books, and Fees
Stipend (i.e., costs related to room, personal living expenses, and/or board)
Dependent Allowance
Supplies
Technology (i.e., computers, and relates items)
Required Program Travel
Miscellaneous (explain)
TOTAL	$[Sum of above]

□ Amounts listed above are final. This box will be checked if the cumulative totals above represent the final amounts for this participant. This box will only be checked if the participant has completed the program or exited the program prior to completion.

VERIFY PAYBACK DETAILS

○ I certify that the payback details entered by my IHE are correct.

○ I disagree with the payback details entered by my IHE and will contact the project director and the DCC Help Desk at 1-888-884-7110 or paybackobligations.ed.gov.

E. Service Payback Status

The service obligation information below is current as of your IHE’s last update on [INSERT DATE]. These totals are expected to increase if you are currently receiving funding or expect to receive more funding prior to the completion of your program; therefore this may not be your final service payback in months and dollars. When you complete or exit the program, your IHE will update your record with your final service payback details. If you have questions regarding this information, please contact your IHE. For definitions of the terms below, please click on any of the underlined links. [ALL FIELDS IN TABLE BELOW ARE PRE-FILLED]

Total Months of Funding:		Total Funding Received:
Total Service Payback Owed:		Total Grace Period Provided per Program Regulations:	6 months
Program Completion Status:		Total Time Remaining in Grace Period:
Total Service Payback Fulfilled to Date (if applicable):		Remaining Service Payback:
Current Service Payback Status:

Click here to view a copy of your service payback agreement.

Notice of Intent [MUST BE COMPLETED WITHIN 30 DAYS OF PROGRAM COMPLETION]

1. *1. Please select one option below to indicate your intent to complete a work-related or cash payback

2.  ○  Work-related payback

I understand by selecting this option I agree to report my employment information in Section F every 6 months until my service payback obligation has been fulfilled.

3.  ○  Cash payback

   1. I understand by selecting this option I will be referred to the U.S. Department of Education’s, Debt and Payment Management Group (DPMG) to establish a repayment plan.

○  I am continuing in a degree program as a full-time student and wish to request an educational deferment to delay service or fiscal payback for funds I received from this grant.

2. I understand by selecting this option I will need to provide the information in Section G.

 F. Eligible Employment

Eligible employment must 1) be related to the training received; and 2) benefit Indian people. Only eligible employment can be submitted for employer verification. You will receive an error message if the position is not eligible and will need to contact the DCC Help Desk at 1-888-884-7110 or paybackobligations@ed.gov for assistance.

Once you enter employment information into DCS an employment record will be created and the record will be sent to your employer for verification. Your employer will have 30 days from the date of submission to verify or dispute the information in the record. For more information on disputed records, click on the "View All Employment Records" link. Note that past employment records cannot be edited once submitted, but current employment records can be edited. You will receive credit for current employment through the date the record was last updated. You cannot update your current employment record during your employer’s 30–day verification period until your employer verifies or disputes the record or the 30-day verification window expires. To update your current employment record, click on the "Update Current Employment" link or on the name of your current employer. Current employment records will be sent to your employer for verification once every 6 months.

Note that if your current full-time position becomes part-time you must add an end date to the current full-time record and create a new record for the part-time position.

As a participant you are required to update DCS with your contact and employment information every 6 months. You will receive reminder emails and phone calls from DCC reminding you to add an employment record or update your current employment record.

If you are within the grace period, or have no changes to your employment, you must check the check box below. Otherwise you must enter employment information.

 □  I do not have changes to my employment at this time.

Employment Record Form

Employment Information

The questions relating to your employment affect your payback status. You must answer every question to the best of your ability. Providing information that you know to be false may be punishable by law.

Employer Information

You must provide the name, address, and phone number of the employer organization for this position. You must list at least one supervisor or human resources manager who can verify your employment and provide his or her e-mail address. You will be asked on the next page to indicate which contact should be sent your employment record for verification. Lastly, you must indicate the type of employer organization for this employment position. Required items are marked with an asterisk.

*Organization Name: ______________________________

(e.g., name of school district, name of government agency)

Department Name: ________________________________

(e.g., school name, government department)

Organization Address

*Address Line 1: Address Line 2:

___________________________ __________________________

*City: *State: *Zip Code:

________________ ___________ ______-____

*Phone: Fax:

_________________ ___________________

TTY: _____________________

Organization Web site address: (Ensure the Web site has the prefix "http://".):

__________________________________

Supervisor

Please provide the name of a supervisor at this job who can verify this employment information.

*First Name: *Last Name:

___________________________ __________________________

Supervisor’s Business Address

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ ___________________

*Email: *Verify Email:

_________________ ________________

Alternate Email Address: Verify Alt. Email:

_________________ ___________________

Fax: TTY:

_____________________ ________________

Human Resource Manager

Please provide the name of a human resources manager at this job who can verify this employment information.

*First Name: *Last Name:

___________________________ __________________________

Human Resource Manager Business Address: 

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ ___________________

*Email: *Verify Email:

_________________ ________________

Alternate Email Address: Verify Alt. Email:

_________________ ___________________

Fax: TTY:

_____________________ _______________

Organization Type
*1. What type of organization is this? Public School Residential School For-profit or Commercial Organization Federal Government Agency (i.e., BIE) State, Local, or Tribal Government Agency	Private School Local Education Agency (LEA) College/University Non-Profit Organization Charter School Other, Please Specify: ______________

Employment Information

Please note - you will not receive credit for more than one full-time position in any given month; For multiple part-time positions, we will count no more than 40 hours per week; and, creditable service is based on actual time worked, not how you are paid (i.e. work 9 months, paid over 12 months, service credit is 9 months).

Past employment records cannot be edited once submitted for verification. Your employer will have 30 days from the date of submission to verify or dispute your employment information for this position. Current employment records can be edited. You will receive credit for current employment up to the date of last update. You cannot update your current employment record during your employer’s 30–day verification period until your employer verifies or disputes the record or the 30-day verification window expires.

While OIE is tracking participant employment in targeted schools with American Indian/Alaska Native enrollment of 5 percent or more, this criteria is not considered a requirement for service payback. Eligible employment for service payback is any employment that is in the participant’s field of study and benefits Indian people (ESEA 7122 (h)(1)(A), 34 CFR 263.8(b)(1)).

Question #10 does not affect your service payback fulfillment status. This question is for measuring performance of the programs at the Office of Indian Education.

To save a record for later completion, please click the "Save For Later" button at the bottom of the page.

*1. Is this your current employment?

• Yes

• No

*2. When did this job begin? __________ (mm/dd/yyyy)

*3. When did this job end? __________ (mm/dd/yyyy)

Please note: past employment records cannot be edited once submitted and verified by employer. Contact the DCS Helpdesk at 1-888-884-7110 or paybackobligations@ed.gov for issues with past employment verification.

*4a. Is this a full-time position?

• Full Time (as defined by your Employer)

• This is a summer position

• This position has summers off

• This is a year round position

*4b. Is this a part-time position?

• Part Time (as defined by your Employer)

• If this employment is part-time, on average, how many hours do you work per week at this job? ______

*4c. Is this a paid position?

• Yes

• No

4d. Would this position be a paid position if funding were available?

• Yes

• No

4e. Does the position have direct involvement with students/school administration?

• Yes

• No

*5. Does this employment benefit American Indian/Alaska Native people?

• Yes

• No

*6. Which of the following best describes the position?

• Paraprofessional/Teacher Assistant/Teacher Aide

• Classroom Teacher

• Assistant Principal

• Principal

• Administrator – LEA (Local Education Agency)

• Administrator – SEA (State Education Agency)

• Administrator – TEA (Tribal Education Agency)

• Social Worker

• Ancillary Education Personnel

• Other, Please Specify:________________

*7. Please select the general education area that best describe this position.

• Administration

• Elementary Education

• Secondary Education

• Social Work

• School or Educational Psychology

• Special Education

*8. Please select the subject area that best describe this position.

• Not Applicable

• Arts and Music

• Bilingual or English as a Second Language

• Early Childhood Education

• English or Language Arts

• Language Education (Native/Heritage/World Languages)

• Health or Physical Education

• Mathematics or Computer Science

• Natural Sciences

• Social Sciences

• Career or Technical Education

• Other (please specify) ____________________

*9. Grade Span [check all that apply]

•  Pre-K

•  K – 5

•  6 – 8

•  9 – 12

•  Other (please specify) ____________________

*10. Do you meet the state certification/licensure requirements for this position?

Select the most appropriate answer.

• Yes

• No

• This state does not have requirements for certification/licensure for this position

• Not applicable to this type of employment position

G. Deferral Request

According to the Program Regulations (in 34 CFR 263.9) available on the DCC website [INSERT LINK], the Secretary may grant a deferral for repayment of a scholarship under any circumstance in which a participant:

1. is engaging in a full-time course of study at an institution of higher education; or

2. is serving on active duty as a member of the armed services of the United States.

Reason for Deferral

• I am engaging in a full-time course of study at an institution of higher education.

• I am serving an active duty as a member of the armed services of the United States.

[If educational deferment display]

You may requestan educational deferment of your service payback if you are continuing as a full-time student without interruption, in a program leading to a degree in an accredited IHE. You must request this deferment within the 6-month grace period after leaving the Professional Development program.

You must also provide the following information:

1. Name of the accredited institution: ________________________________

2. The degree being sought: _______________________________________

3. Date of program completion: ________________ (mm/dd/yyyy)

4. A copy of the letter of admission/Status report [display Status report if deferral is approved from the IHE] The acceptance letter/status report must state your name, date of acceptance into program of study, the degree being sought, that you are enrolled full-time, be on school letterhead, and be signed and dated by a school official.

You may upload an electronic copy of the required documentation or you may mail or fax the documents to the DCC Help Desk at 1600 Research Blvd., RA 1297, Rockville, MD, 20850 or 888-252-6960.

Please upload the appropriate documentation to support your deferral request. Depending on the file size of the attachment, the upload process may take up to several minutes. Acceptable file types include .doc, .docx., .and pdf. Please note that file names or titles cannot have spaces. You may use underscores (e.g., John_Doe_deferral_request.doc).

If your request is approved, you must submit a status report from an authorized academic advisor or other authorized representative of the IHE, showing verification of full-enrollment and status after each semester.

[If military deferment display]

You may request a military deferment is you exit the Professional Development program because you are called or ordered to active duty status in connection with a war, military operation, or national emergency for more than 30 days as a member of a reserve component of the Armed Forces named in 10 U.S.C. 10101, or as a member of the National Guard on full-time National Guard duty, as defined in 10 U.S.C. 101(d)(5). The Secretary may defer the payback requirement until you have completed your military service, for a period not to exceed 36 months. You must request the deferral within 30 days of the earlier of receiving the call to military service or completing or exiting the Professional Development program.

You must also provide the following information:

1. Date on which service began: ________________ (mm/dd/yyyy)

2. Date on which service service is expected to end: ________________ (mm/dd/yyyy)

3. A written statements from your commanding or personnel officer certifying that you are on active duty in the Armed Forms of the United States; the date on which your service began; the date on which your service is expected to end.

4. A true certified copy of yourofficial military orders.

5. A copy of the your military identification.

You may upload an electronic copy of the required documentation or you may mail or fax the documents to the DCC Help Desk at 1600 Research Blvd., RA 1297, Rockville, MD, 20850 or 888-252-6960.

Please upload the appropriate documentation to support your deferral request. Depending on the file size of the attachment, the upload process may take up to several minutes. Acceptable file types include .doc, .docx., .and pdf. Please note that file names or titles cannot have spaces. You may use underscores (e.g., John_Doe_deferral_request.doc).

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