Verification of Teacher Obligation

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 received

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 school, 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 teaching 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 information 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 A5 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 e-mail this completed form to Karen.Wilson@ed.gov or mail it to:

U.S. Department of Education

Office of Postsecondary Education

Teacher Quality Enhancement Program

400 Maryland Avenue SW, 5E109

Washington, DC 20202

Thank you for your assistance.

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)

 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 students 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 school’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 significant 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 teaching, 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. *

_________________________________________ _____________________________

Signature of School District Official Date

_________________________________________ _____________________________

Name of School District Official Title

* Note: Please provide original signature. Do not use rubber stamp.

3. 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 previously completed SECTIONS I and II.)

Part A.

_______________________________________________

(Name of Teacher)

1.  Continued to teach at: _______________________________________________________

(School Name)

for the remainder of the school year 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 semesters 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 employed by the school district or worked in a high-need school.

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Questions / Comments: ____________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

I certify that information contained in this document concerning ____________________________ is correct.

(Name of Teacher)

_________________________________________ _________________________

Signature of School District Official * Date

_________________________________________ _________________________

Name of School District Official Title

* Original signature required. Do not use stamp.

Privacy Act Notice

The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you. 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, 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 Enhancement 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. The 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 your 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 complied 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. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may also send this information to law enforcement 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 Treasury and to credit agencies to verify the identity and location of the debtor and to the Department of Treasury, collection agencies, and employers of the scholarship recipient in order to service or collect on the debt. We may send information to members of Congress if you ask them to help you with questions related to this Program. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. If necessary for the Department to obtain advice from the DOJ, we can disclose information to the DOJ. We 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 particular records. We can disclose records to contractors if we contract with an entity to perform functions that require the disclosure of the records. Disclosures may also be made to qualified researchers under Privacy Act safeguards. Finally, disclosures may be made to OMB as necessary under the requirements of the Credit Reform Act. You must provide all of the information requested in order to have your request for tuition reimbursement processed.

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 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 (Title II, Section 204(e) of the Higher Education Act of 1965, as amended, and 31 U.S.C. Chapter 37). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to regulations.gov during the public comment period for this collection of information.  If you have specific questions about the form, instrument or survey, please contact the U.S. Department of Education, Office of Postsecondary Education, Teacher Quality Enhancement Program, 400 Maryland Ave SW, Room 5E109, Washington, DC 20202.

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