Scholar/Obligee Record Form

Personnel Development Program Data Collection System: Scholar/Obligee Record Form

(Completed by Institution of Higher Education)

OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

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 25 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 maintain benefits (Individuals with Disabilities Education Act of 2004 (IDEA) and its corresponding, regulations, 34 CFR Part 304). 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 1820-0686. Note: Please do not return the completed Scholar/Obligee Record Form to this address.

Rules of Behavior for Department of Education-Sponsored Website

The Office of Special Education Program’s Personnel Development Program (PDP) Data Collection System (DCS) is an online data collection system designed to facilitate administration of the PDP Program. This system collects employment and contact information from participating scholar/obligees to verify the fulfillment of their service obligation and assess program performance. Verifying service obligation requires collecting personally identifying information from Institutions of Higher Education, scholars/obligees, and employers. This data collection has been authorized by the Individuals with Disabilities Education Act of 2004 (IDEA) and its corresponding requirements 34 CFR Part 304 printed in the Federal Register Volume 70 No. 57 March 25, 2005 and regulations Vol. 71 No. 107 June 5, 2006, and the Government Performance and Results Act of 1993, section 4.

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 grantee access to the DCS. Users representing grantees agree to:

• Maintain requested grant information, including grant contact information;

• Maintain DCS accounts established to collect grant, grantee and scholar/obligee information by:

  • Protecting account login names and passwords;

  • Submitting scholar/obligee information as requested by DCS;

  • Reviewing scholar/obligee information for accuracy; and

  • Protecting the confidentiality of personally identifying information requested by DCS.

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

□ I agree to the terms.

Institution of Higher Education

Scholar/Obligee Record Form Instructions

• Required Fields: Please complete the following questions for the scholar/obligee record. Required items are marked with an asterisk.

• Entering Scholars: Please note that scholars/obligees may only be entered into the DCS under one OSEP grant at a time. If a scholar/obligee is funded sequentially under multiple OSEP funded grants, please exit the scholar from the first OSEP grant and assure that the scholar completes the Exit Certification from that OSEP grant. Then, the scholar and grantee must submit a new Pre-Scholarship Agreement under the next OSEP grant from which the scholar will receive funds. Please contact the Data Collection Center (DCC) HelpDesk for further information, if needed.

• System Timing Out: You will be logged out of the system after 30 minutes of inactivity. A warning message will appear after 25 minutes of inactivity.

• Saving and Submitting Records: To save a record for future editing or completion, click on the SAVE button. This will create a pending record. When a student has completed or exited the program and all the required information has been entered, check the box in Section L. Then, click on the SUBMIT button. When the record is “submitted,” it CANNOT be edited. To edit submitted records, please contact the DCC Helpdesk. Once a record is submitted for an exited or completed scholar/obligee, the scholar/obligee is given access to the database for input of employment information.

• Scholar/oblige access to system: Currently enrolled scholars/obligees are given access to the system when their records are submitted, if they have completed one or more academic years of training which makes them eligible to begin fulfilling their service obligation. 2006 Regulations: §304.30(f)(2). Records submitted for currently enrolled scholars/obligees can be edited.

Grant Award Number: [PRE-FILLED]

A. Identifying Information
*First Name			Middle Name		*Last Name
Maiden Name, if applicable:
*Social Security Number			--	--
*Date of Birth
*Primary E-mail Address
*Verify Primary E-mail Address
Alternative E-mail Address
Verify Alternative E-mail Address
* Required fields necessary to submit a record.

For grants awarded prior to FY 2012, please enter the 3-digit Scholar Data Report ID: __ __ __

B. Contact Information
Primary Address
*Address
*City		*State		*Zip Code1
*Home Phone		Cell Phone
	(XXX) XXX-XXXX		(XXX) XXX-XXXX
Secondary Address
Address
City		State		Zip Code
Other Phone		Fax
	(XXX) XXX-XXXX		(XXX) XXX-XXXX
* Required fields necessary to submit a record.

C. Alternate Contact2 Information

*First Name

*Last Name

*E-mail Address

*Verify Primary E-mail Address

*Address

*City

*State

*Zip Code3

*Home Phone

Other Phone

(XXX) XXX-XXXX

(XXX) XXX-XXXX

* Required fields necessary to submit a record.

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 year. [This instruction and the check box will not be displayed the first time a scholar/obligee record is created and submitted.]

□ No changes necessary.

D. Pre-Scholarship Agreement

Please submit the Pre-Scholarship Agreement for this scholar.

[See attached Pre-Scholarship Agreement.]

E. Scholar Demographic Information

Section E only needs to be completed once. Once the record has been submitted, you must contact DCC to edit any of these items.

1. What is this scholar’s gender?

• Female

• Male

2. Is this scholar of Hispanic or Latino origin?

• Yes

• No

3. What is this scholar’s race? Check all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

4. Does this scholar have a disability?

• Yes

• No

• Unknown

5. What is this scholar’s current age?

• Under 21

• 21-29

• 30-39

• 40-49

• 50 and over

F. Training and Employment Prior to Entry into OSEP Grant Training

Section F only needs to be completed once. Once the record has been submitted, you must contact DCC to edit any of these items.

*1. Check the degree(s) or certificate(s) or endorsement(s) the participant held when he/she entered this OSEP grant-supported training (check all that apply):

• High school diploma or equivalency [If only degree, go to Question 5]

• Associate’s Degree

• Bachelor's Degree

• Master's Degree

• Educational Specialist

• Doctoral Degree

• Postdoctoral Degree

• State or Professional Credential/Certificate

• State-issued Endorsement

*2. If scholar was granted a degree/certificate/endorsement prior to entry into this OSEP grant-supported training, the area(s) was: (check all that apply)

• General education (If general education only, go to question 3)

• Special education or related services (Select training area under 2b)

• Outside the field of education (If outside of the field of education only, go to question 5)

2b. If special education or related services is checked under 2a above, select one special education and/or one related services training area that best describes the focus of the scholar’s degree/certificate/endorsement prior to entry into this OSEP grant-supported training.

Training Area	I. Special Education	Training Area	II. Related Services
	General special education, cross-categorical, generic, multi-categorical, or non-categorical		Audiology
			Counseling
			Educational diagnostician
	General special education, mild or moderate		Interpreter/ASL
	Low incidence disabilities/multiple disabilities/ severe disabilities		Music therapy
			Nursing
	Combined studies: general education and special education		Occupational therapy
			Orientation & mobility
	Developmental delay		Paraprofessional
	Specific learning disabilities		Physical therapy
	Speech/language impairment		Rehabilitation counseling
	Emotional disturbance/behavioral disorders		School counseling
	Autism		Psychology
	Traumatic brain injury		Speech/language
	Deafness and/or hard-of-hearing		Social work
	Visual impairment and/or blindness		Therapeutic recreation
	Deaf/blindness		Work experience coordinator (Employment transition specialist)
	Intellectual disability: mild/moderate
	Intellectual disability: severe
	Other health impairment
	Physical impairment/orthopedic impairment
	Adapted physical education
	Assistive technology
	Bilingual special education/ESL/TESOL
	Early childhood/early intervention
	Special education for youth in correctional facilities
	Secondary transition

2c. If appropriate, select up to three additional training areas to provide more detailed information about the scholar’s focus of training prior to entry into this OSEP grant-supported training.

Training Area	I. Special Education	Training Area	II. Related Services
	General special education, cross-categorical, generic, multi-categorical, or non-categorical		Audiology
			Counseling
			Educational diagnostician
	General special education, mild or moderate		Interpreter/ASL
	Low incidence disabilities/multiple disabilities/ severe disabilities		Music therapy
			Nursing
	Combined studies: general education and special education		Occupational therapy
			Orientation & mobility
	Developmental delay		Paraprofessional
	Specific learning disabilities		Physical therapy
	Speech/language impairment		Rehabilitation counseling
	Emotional disturbance/behavioral disorders		School counseling
	Autism		Psychology
	Traumatic brain injury		Speech/language
	Deafness and/or hard-of-hearing		Social work
	Visual impairment and/or blindness		Therapeutic recreation
	Deaf/blindness		Work experience coordinator (Employment transition specialist)
	Intellectual disability: mild/moderate
	Intellectual disability: severe
	Other health impairment
	Physical impairment/orthopedic impairment
	Adapted physical education
	Assistive technology
	Bilingual special education/ESL/TESOL
	Early childhood/early intervention
	Special education for youth in correctional facilities
	Secondary transition

3. If prior training was in special education, other education, or related services, what age(s) or grades of children was the scholar trained to provide direct or indirect services to? (check one)

• Early intervention (infants and toddlers)

• Early childhood (preschool, ages 3 – 5, ages 3 – 8)

• Birth through age 8

• Elementary (grades K – 6^th, K – 8^th, PreK – 6^th, PreK – 8^th)

• Middle/Jr. High school (grades 6^th – 8^th, 7^th – 9^th)

• High school (grades 9^th – 12^th, 10^th – 12^th)

• Junior/senior high combined

• Grades K – 12

• Birth through young adult (birth – age 21, birth – age out)

• Adolescents through post-secondary age/young adult

• Post-secondary age/young adult (18 – 22 years, 18 – 25 years)

• Adults with disabilities

• All ages, birth through adulthood

4. Has this scholar received funding under a different OSEP training grant?

• Yes (Please specify grant number _________________________)

• No

5a. How many credit hours did this scholar earn prior to enrollment that were accepted towards completion of this OSEP grant-supported program? _________________________

5b. What is the total number of credit hours required to complete this program? _____________________

6. Was the scholar employed during the academic year, prior to entry into this OSEP grant-supported training?

• Yes

• No (Go to Section G)

7. In what state was the scholar working? ___ ___ (State abbreviation)

(Use online pull down box to select state or the outside of the country option)

8. Choose one type of employment that best describes the pre-entry position of this scholar:

• Special education teacher

• General education teacher (not special education)

• Early interventionist, early childhood, or early childhood service provider

• Special education paraprofessional/aide

• General education paraprofessional/aide (not special education)

• Early intervention, early childhood special education, or early childhood paraprofessional/aide

• Related or supportive service provider in early intervention, early childhood or in a school setting

• Related or supportive service provider in a non-school setting (e.g., child find services)

• Administrator/Coordinator/Supervisor (including the capacity of a principal)

• Instructional Specialist

• Higher education (e.g., faculty, research assistant, practicum coordinator) (If selected, go to question 9 and then Section G

• Other, within education (please specify)

• Outside the field of education (If selected, go to Section G)

9. What age(s) or grades of children did the scholar provide direct or indirect services to in this pre-entry position? (Check one)

• Early intervention (infants and toddlers)

• Early childhood (preschool, ages 3 – 5, ages 3 – 8)

• Birth through age 8

• Elementary (grades K – 6th, K – 8th, PreK – 6th, PreK – 8th)

• Middle/Jr. High school (grades 6th – 8th, 7th – 9th)

• High school (grades 9th – 12th, 10th – 12th)

• Junior/senior high combined

• Grades K – 12

• Birth through young adult (birth – age 21, birth – age out)

• Adolescents through post-secondary age/young adult

• Post-secondary age/young adult (18 – 22 years, 18 – 25 years)

• Adults with disabilities

• All ages, birth through adulthood

10. Was this scholar {highly qualified/qualified/fully certified} for this position under the Individuals with Disabilities Education Act (IDEA) and has not had certification or licensure requirements waived on an emergency, temporary or provisional basis? {Highly qualified/Qualified/Fully certified} for purposes of this data collection means that the scholar meets the state requirements, if there are requirements in your state, for certification/licensure for this position.

• {Highly qualified/Qualified/Fully certified}

• {Not highly qualified/Not qualified/Not fully certified}

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

[Note: If the position (FQ8) is an elementary or secondary general education/special education teacher, display “highly qualified”; if the position is general education/special education paraprofessional/aide or early intervention, early childhood or preschool paraprofessional/aide, display “qualified”; or if the position is administrator/coordinator, for related or supportive services in a school setting, or for teacher, related services, or supportive services in early intervention, early childhood, display “fully certified.”]

G. Current Training Program Information

*1. Date scholar enrolled in OSEP training program: __________ (mm/yyyy)

*2. Check the degree(s) or certificate(s) or endorsement(s) the scholar is pursuing through this special education or related services training grant: (Check all that apply)

• Associate’s degree

• Bachelor’s degree

• Master’s degree

• Educational specialist

• Doctoral degree

• Postdoctoral degree

• State or professional credential/certificate

• State-issued endorsement

• Course completion only; no degree(s), certificate(s), or endorsement(s) will be awarded when the scholar completes the OSEP grant-supported training

*3. What age(s) or grades of children is the scholar training to provide direct or indirect services to? (Check one)

• Early intervention (infants and toddlers)

• Early childhood (preschool, ages 3 – 5, ages 3 – 8)

• Birth through age 8

• Elementary (grades K – 6^th, K – 8^th, PreK – 6^th, PreK – 8^th)

• Middle/Jr. High school (grades 6^th – 8^th, 7^th – 9^th)

• High school (grades 9^th – 12^th, 10^th – 12^th)

• Junior/senior high combined

• Grades K – 12

• Birth through young adult (birth – age 21, birth – age out)

• Adolescents through post-secondary age/young adult

• Post-secondary age/young adult (18 – 22 years, 18 – 25 years)

• All ages, birth through adulthood

*4a. Select one special education and/or one related services training area that best describes the training focus for which the scholar is enrolled.

Training Area	I. Special Education	Training Area	II. Related Services
	General special education, cross-categorical, generic, multi-categorical, or non-categorical		Audiology
			Counseling
			Educational diagnostician
	General special education, mild or moderate		Interpreter/ASL
	Low incidence disabilities/multiple disabilities/ severe disabilities		Music therapy
			Nursing
	Combined studies: general education and special education		Occupational therapy
			Orientation & mobility
	Developmental delay		Paraprofessional
	Specific learning disabilities		Physical therapy
	Speech/language impairment		Rehabilitation counseling
	Emotional disturbance/behavioral disorders		School counseling
	Autism		Psychology
	Traumatic brain injury		Speech/language
	Deafness and/or hard-of-hearing		Social work
	Visual impairment and/or blindness		Therapeutic recreation
	Deaf/blindness		Work experience coordinator (Employment transition specialist)
	Intellectual disability: mild/moderate
	Intellectual disability: severe
	Other health impairment
	Physical impairment/orthopedic impairment
	Adapted physical education
	Assistive technology
	Bilingual special education/ESL/TESOL
	Early childhood/early intervention
	Special education for youth in correctional facilities
	Secondary transition

Notice to 325D (Leadership) grantees: If the special education and related services areas above are not appropriate for the training focus of your grant, please provide a brief description of the scholar’s training focus below.

4b. If appropriate, select up to three additional training areas to provide more detailed information about the scholar’s focus of training.

Training Area	I. Special Education	Training Area	II. Related Services
	General special education, cross-categorical, generic, multi-categorical, or non-categorical		Audiology
			Counseling
			Educational diagnostician
	General special education, mild or moderate		Interpreter/ASL
	Low incidence disabilities/multiple disabilities/ severe disabilities		Music therapy
			Nursing
	Combined studies: general education and special education		Occupational therapy
			Orientation & mobility
	Developmental delay		Paraprofessional
	Specific learning disabilities		Physical therapy
	Speech/language impairment		Rehabilitation counseling
	Emotional disturbance/behavioral disorders		School counseling
	Autism		Psychology
	Traumatic brain injury		Speech/language
	Deafness and/or hard-of-hearing		Social work
	Visual impairment and/or blindness		Therapeutic recreation
	Deaf/blindness		Work experience coordinator (Employment transition specialist)
	Intellectual disability: mild/moderate
	Intellectual disability: severe
	Other health impairment
	Physical impairment/orthopedic impairment
	Adapted physical education
	Assistive technology
	Bilingual special education/ESL/TESOL
	Early childhood/early intervention
	Special education for youth in correctional facilities
	Secondary transition

Please review and verify the information in Section G Items 1 through 4. Check the box below if there have been no changes in the last year. [This instruction and the check box will not be displayed the first time a scholar/obligee record is created and submitted.]

□ No changes necessary.

Note: Section G, Items 5 and 6 must be completed annually for scholars who were enrolled in the OSEP-grant program during the current budget year.

*5. During the current or most recent grant budget year, was this scholar considered by your institution to be a full-time or part-time scholar?

Grant Fiscal Year	Full-time scholar, even if the scholar worked full-time or part-time	Part-time scholar (anything less than full-time)
[PRELOAD DATES FY 1]	Full-time scholar	Part-time scholar
[PRELOAD DATES FY 2]	Full-time scholar	Part-time scholar
[PRELOAD DATES FY 3]	Full-time scholar	Part-time scholar
[PRELOAD DATES FY 4]	Full-time scholar	Part-time scholar
[PRELOAD DATES FY 5]	Full-time scholar	Part-time scholar
[PRELOAD DATES FY 6]	Full-time scholar	Part-time scholar
[PRELOAD DATES FY 7]	Full-time scholar	Part-time scholar

[Grantee will only be able to edit the row for the current budget year and prior years]

*6. Specify the total amount of funding this scholar received directly from this OSEP-supported training grant during the current or most recent grant budget year. In calculating the total amount, include any training stipend funds used for tuition and fees, scholar stipends, books, travel in conjunction with training assignments, and other associated training expenses. Please enter $0 for a scholar who was enrolled in the grant program but did not receive funding during the current budget year.

Grant Fiscal Year	Funding Amount
[PRELOAD DATES FY 1]	$
[PRELOAD DATES FY 2]	$
[PRELOAD DATES FY 3]	$
[PRELOAD DATES FY 4]	$
[PRELOAD DATES FY 5]	$
[PRELOAD DATES FY 6]	$
[PRELOAD DATES FY 7]	$
Total	$[SUM ABOVE]

[Grantee will only be able to edit the row for the current budget year.]

 H. Employment Information During OSEP Grant Program

*1. During the current or most recent grant budget year, was this scholar employed?

Grant Fiscal Year	Employed
[PRELOAD DATES FY 1]	Yes	No
[PRELOAD DATES FY 2]	Yes	No
[PRELOAD DATES FY 3]	Yes	No
[PRELOAD DATES FY 4]	Yes	No
[PRELOAD DATES FY 5]	Yes	No
[PRELOAD DATES FY 6]	Yes	No
[PRELOAD DATES FY 7]	Yes	No

[Grantee will only be able to edit the row for the current budget year and prior years. If scholar is not employed during current budget year, go to Section I.]

2. If yes, enter the average number of hours per week this scholar was employed:

_______(Round to the nearest hour)

*3. Is this position:

• Same position held before entry to this OSEP grant-supported training (Go to Section I.)

• For continuing scholars only, same position held in previous budget year (Go to Section I.)

• Different or new position (Proceed to question 4)

4. Choose one type of employment that best describes this scholar’s position:

• Special education teacher

• General education teacher (not special education)

• Early interventionist, early childhood, or early childhood service provider

• Special education paraprofessional/aide

• General education paraprofessional/aide (not special education)

• Early intervention, early childhood special education, or early childhood paraprofessional/aide

• Related or supportive service provider in early intervention, early childhood or in a school setting

• Related or supportive service provider in a non-school setting (e.g., child find services)

• Administrator/Coordinator/Supervisor (including the capacity of a principal)

• Instructional Specialist

• Higher education (e.g., faculty, research assistant, practicum coordinator) (If selected, go to question 5 and then Section I)

• Other, within education (please specify)

• Outside the field of education (If selected, go to Section I)

5. If the scholar is employed in education, special education or related services, what age(s) or grades of children does the scholar provide direct or indirect services to? (Check one)

• Early intervention (infants and toddlers)

• Early childhood (preschool, ages 3 – 5, ages 3 – 8)

• Birth through age 8

• Elementary (grades K – 6th, K – 8th, PreK – 6th, PreK – 8th)

• Middle/Jr. High school (grades 6th – 8th, 7th – 9th)

• High school (grades 9th – 12th, 10th – 12th)

• Junior/senior high combined

• Grades K – 12

• Birth through young adult (birth – age 21, birth – age out)

• Adolescents through post-secondary age/young adult

• Post-secondary age/young adult (18 – 22 years, 18 – 25 years)

• All ages, birth through adulthood

6. Is this scholar {highly qualified/qualified/fully certified} for this position under IDEA? {Highly qualified/Qualified/Fully certified} for purposes of this data collection means that the scholar meets the state requirements, if there are requirements in your state, for certification/licensure for this position.

• {Highly qualified/Qualified/Fully certified}

• {Not highly qualified/Not qualified/Not fully certified}

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

[Note: If the position (HQ4) is an elementary or secondary general education/special education teacher, display “highly qualified”; if the position is general education/special education paraprofessional/aide or early intervention, early childhood or preschool paraprofessional/aide, display “qualified”; or if the position is administrator/coordinator, for related or supportive services in a school setting, or for teacher, related services, or supportive services in early intervention, early childhood, display “fully certified.”]

 I. Scholar Status

Please indicate the appropriate program status of the scholar/obligee below. You must complete all subquestions for the option selected.

1. Program Duration:

Select the most appropriate option below.

○ This program is less than one academic year in duration.

○ This program is more than one academic year in duration, but the scholar/obligee has not yet completed one academic year of training.

○ This program is more than one academic year in duration and the scholar/obligee completed one academic year of training on __________ (mm/dd/yyyy).

2. *Scholar/obligee program status:
Select the most appropriate option below.

○ The scholar/obligee is still enrolled in the program and is currently receiving OSEP funding.

○ The scholar/obligee is still enrolled in the program but is no longer receiving OSEP funding because:

○	Grant support terminated due to OSEP grant ending.

Please enter the date the OSEP grant ended: __________ (mm/dd/yyyy)

(The date above reflects the most recent end date in the grant profile. If you edit the grant end date, you will be prompted to update the grant profile.)

○ Please enter the date of scholar exit/graduation/completion, if applicable.

__________ (mm/dd/yyyy) and submit the Exit Certification (with scholar).

Is it expected that the scholar will continue enrollment in another OSEP-supported training to complete the scholar’s program?
○ Yes

If yes, what is the grant number? ________________________

(Submit a Pre-Scholarship Agreement with the scholar for the new OSEP grant under which the scholar will receive funding.)

○  No

○  Don’t know

○ Other

Please specify other reason scholar/obligee is no longer receiving OSEP funding but is still enrolled.

___________________________________________________________

Is it expected that the scholar will be enrolled in an program supported by an OSEP grant at a future date?
○ Yes

○  No

○  Don’t know

○ The scholar/obligee exited/graduated/completed the program

Please enter the date of exit/graduation/completion, if applicable.

__________ (mm/dd/yyyy)

○ The scholar/obligee exited without graduating/completing the program.

Please enter the date of exit without completion:__________ (mm/dd/yyyy)

What are the reason(s) that the scholar/obligee is no longer enrolled in this program? (Check all that apply)

□	Transferred to another training program in special education or related services
□	Transferred to another program NOT in special education or related services
□	Financial stress or burden
□	Health (physical/emotional) of self or family member
□	Moved
□	Obtained employment
□	Other personal reasons
□	Poor academic performance
□	Poor practicum/field-based performance

Is it expected that the scholar will be enrolled in a program supported by an OSEP grant at a future date?
○ Yes
○ No
○ Don’t know

J. Scholar Exit Information

*1.What degree(s) or certificate(s) or endorsement(s) did this scholar receive as a result of completing this OSEP grant-supported training: (Check all that apply)

• Associate’s degree

• Bachelor’s degree

• Master’s degree

• Educational specialist

• Doctoral degree

• Postdoctoral degree

• State or professional credential/certificate

• State-issued endorsement

*2a. Select one special education and/or one related services training area that best describes the training focus of the degree(s) or certificate(s) or endorsements(s) that this scholar received from this OSEP grant-supported training.

Training Area	I. Special Education	Training Area	II. Related Services
	General special education, cross-categorical, generic, multi-categorical, or non-categorical		Audiology
			Counseling
			Educational diagnostician
	General special education, mild or moderate		Interpreter/ASL
	Low incidence disabilities/multiple disabilities/ severe disabilities		Music therapy
			Nursing
	Combined studies: general education and special education		Occupational therapy
			Orientation & mobility
	Developmental delay		Paraprofessional
	Specific learning disabilities		Physical therapy
	Speech/language impairment		Rehabilitation counseling
	Emotional disturbance/behavioral disorders		School counseling
	Autism		Psychology
	Traumatic brain injury		Speech/language
	Deafness and/or hard-of-hearing		Social work
	Visual impairment and/or blindness		Therapeutic recreation
	Deaf/blindness		Work experience coordinator (Employment transition specialist)
	Intellectual disability: mild/moderate
	Intellectual disability: severe
	Other health impairment
	Physical impairment/orthopedic impairment
	Adapted physical education
	Assistive technology
	Bilingual special education/ESL/TESOL
	Early childhood/early intervention
	Special education for youth in correctional facilities
	Secondary transition

Notice to 325D (Leadership) grantees: If the special education and related services areas above are not appropriate for the training focus of your grant, please provide a brief description of the training focus of the scholar’s degree(s) or certificate(s) or endorsements(s) below.

2b. If appropriate, select up to three additional training areas to provide more detailed information about the scholar’s focus of training.

Training Area	I. Special Education	Training Area	II. Related Services
	General special education, cross-categorical, generic, multi-categorical, or non-categorical		Audiology
			Counseling
			Educational diagnostician
	General special education, mild or moderate		Interpreter/ASL
	Low incidence disabilities/multiple disabilities/ severe disabilities		Music therapy
			Nursing
	Combined studies: general education and special education		Occupational therapy
			Orientation & mobility
	Developmental delay		Paraprofessional
	Specific learning disabilities		Physical therapy
	Speech/language impairment		Rehabilitation counseling
	Emotional disturbance/behavioral disorders		School counseling
	Autism		Psychology
	Traumatic brain injury		Speech/language
	Deafness and/or hard-of-hearing		Social work
	Visual impairment and/or blindness		Therapeutic recreation
	Deaf/blindness		Work experience coordinator (Employment transition specialist)
	Intellectual disability: mild/moderate
	Intellectual disability: severe
	Other health impairment
	Physical impairment/orthopedic impairment
	Adapted physical education
	Assistive technology
	Bilingual special education/ESL/TESOL
	Early childhood/early intervention
	Special education for youth in correctional facilities
	Secondary transition

3. Did the scholar take an exam or measure to demonstrate knowledge and skills prior to completing this OSEP funded-training program?

• Yes (If selected, go to question 4)

• No (If selected, go to Section K)

• Don’t know (If selected, Section K)

4a-e. Please select the exam or measure the scholar took to demonstrate knowledge and skills.

Drop Down List of Measures (See Appendix A for complete list)

5a-e. Did the scholar pass this exam or measure?

• Yes

• No

• Don’t know

• Not applicable, our state does not set a passing score. (If selected, go to question 6)

6a-d. Did the scholar take any other exam(s) or measure(s) to demonstrate knowledge and skills prior to completing this OSEP-funded training program?

• Yes (If selected, repeat questions 4 to 6 until no other measures, up to 5 total)

• No (If selected, go to Section K)

• Don’t know (If selected, go to Section K)

K. Service Obligation Information and Exit Certification

*Please submit Exit Certification.

Both grantee and scholar/oblige must complete an Exit Certification Form within the online, secure system.

[See attached Exit Certification.]

L. Information Verification

• Saving and Submitting Records: To save a record for future editing or completion, click on the SAVE button. This will create a pending record. When a student has completed or exited the program and all the required information has been entered, check the box in Section L. Then, click on the SUBMIT button. When the record is “submitted,” it CANNOT be edited. To edit submitted records, please contact the DCC Helpdesk. Once a record is submitted for an exited or completed scholar/obligee, the scholar/obligee is given access to the database for input of employment information.

 □   Yes, all information available for this scholar/obligee has been entered.

Appendix A: List of Measures of Knowledge and Skills

The following options will be presented in a linked pair of dropdown menus. The first drop down menu will contain the main options. The second drop down menu will dynamically populate with the secondary list based on the current selection in the first.

Category	Specific Assessment of Knowledge and Skills
Grantee specific test	Comprehensive Exams Defense of Dissertation Final Oral Exam for Master's Degree Portfolio Practicum Supervisor evaluation Teaching Performance Assessment Thesis Other Specify _________________________
National organization test	Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP) Certification Exam Adapted Physical Education National Standards (APENS) Exam American Physical Therapy Association (APTA) Pediatric Specialist Certification American Sign Language Teachers Association (ASLTA) Evaluation Interview Board Certified Behavior Analyst (BCBA) Exam Educational Interpreter Performance Assessment (EIPA) National Blindness Professional Certification Board (NBPCB) National Orientation and Mobility Certification Exam National Board for Professional Teaching Standards (NBPTS) Certificate National Board for the Certification of Occupational Therapists (NBCOT) Certification National Counselor Examination (NCE) The National Council for Therapeutic Recreation Certification (NCTRC) The National Physical Therapy Examination (NPTE) Reading Instruction Competence Assessment (RICA) Registry of Interpreters for the Deaf (RID) Certificate of Interpretation and Certificate of Transliteration (CI/CT) Registry of Interpreters for the Deaf (RID)/National Association of the Deaf (NAD)-National Interpreter Certification Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) Assistive Technology Practitioner (ATP) Sign Language Proficiency Interview (SLPI) Other Specify _________________________
PRAXIS II	Audiology Early Childhood: Content Knowledge Early Childhood Education Education of Deaf and Hard of Hearing Students Education of Exceptional Students: Core Content Knowledge Education of Exceptional Students: Learning Disabilities Education of Exceptional Students: Mild to Moderate Disabilities Education of Exceptional Students: Severe to Profound Disabilities Education of Young Children Educational Leadership: Administration and Supervision Elementary Education: Content Area Exercises Elementary Education: Content Knowledge Elementary Education: Curriculum, Instruction, and Assessment English Language, Literacy, and Composition: Content Knowledge Fundamental Subjects: Content Knowledge Interdisciplinary Early Childhood Education Introduction to the Teaching of Reading Middle School: Content Knowledge Middle School English Language Arts Middle School Mathematics Pre-Kindergarten Education Principles of Learning and Teaching: Early Childhood Principles of Learning and Teaching: Grades K-6 Principles of Learning and Teaching: Grades 5-9 Principles of Learning and Teaching: Grades 7-12 Reading Across the Curriculum: Elementary Reading Across the Curriculum: Secondary School Psychologist Special Education: Application of Core Principles Across Categories of Disability Special Education: Knowledge-delivered Core Principles Special Education: Preschool/Early Childhood Special Education: Teaching Students with Behavioral Disorders/Emotional Disturbances Special Education: Teaching Students with Learning Disabilities Special Education: Teaching Students with Mental Retardation Speech Communication: Content Knowledge Speech-Language Pathology Teaching Foundations: Mathematics Teaching Foundations: English Teaching Speech to Students with Language Impairments Teaching Students with Visual Impairments Other Specify _________________________
State specific test	Alabama (AL) Alabama Prospective Teacher Testing Program (APTTP)/Alabama WorkKeys Applied Mathematics Reading for Information Writing Arizona (AZ) Arizona Educator Proficiency Assessment (AEPA) Professional Knowledge: Early Childhood Professional Knowledge: Elementary Professional Knowledge: Secondary Subject Knowledge: Early Childhood Education Subject Knowledge: Elementary Education Subject Knowledge: Special Education: Cross-categorical Subject Knowledge: Special Education: Early Childhood Subject Knowledge: Special Education: Emotional Disability Subject Knowledge: Special Education: Hearing Impaired Subject Knowledge: Special Education: Learning Disability Subject Knowledge: Special Education: Mental Retardation Subject Knowledge: Special Education: Orthopedic Impairments/Other Health Impairments Subject Knowledge: Special Education: Severely and Profoundly Disabled Subject Knowledge: Special Education: Speech and Language Impaired Subject Knowledge: Special Education: Visually Impaired California (CA) California Basic Educational Skills Test (CBEST) California Subject Examinations for Teachers (CSET) Multiple Subjects I Multiple Subjects II American Sign Language (ASL) I American Sign Language (ASL) II American Sign Language (ASL) III Performance Assessment for California Teachers (PACT) California Teaching Performance Assessment (CalTPA) Fresno Assessment of Student Teachers (FAST) Colorado (CO) Program for Licensing Assessments for Colorado Educators (PLACE) Administrator Art Basic Skills Drama Early Childhood Education Early Childhood Special Education Elementary Education English Health Linguistically Diverse Linguistically Diverse Bilingual Education Mathematics Music Physical Education Principal Reading Specialist Reading Teacher School Counselor School Social Worker Science Social Studies Spanish Special Education Generalist Special Education: Severe Needs- Deaf/Hard of Hearing Special Education: Severe Needs-Visually Impaired Speech Florida (FL) Florida Teacher Certification Examinations (FTCE) General Knowledge Test (GK) Professional Education Test (PEd) Subject Area Examinations (SAE): Elementary Education K-6 Subject Area Examinations (SAE): English 6-12 Subject Area Examinations (SAE): Exceptional Student Education K-12 Subject Area Examinations (SAE): Hearing Impaired K-12 Subject Area Examinations (SAE): Mathematics Subject Area Examinations (SAE): Middle Grades English 5-9 Subject Area Examinations (SAE): Mathematics 5-9 Subject Area Examinations (SAE): Prekindergarten/Primary PK-3 Subject Area Examinations (SAE): Preschool Education Birth-Age 4 Subject Area Examinations (SAE): Reading K-12 Subject Area Examinations (SAE): Speech-Language Impaired K-12 Subject Area Examinations (SAE): Visually Impaired K-12 Florida Educational Leadership Examination (FELE) Florida Registry of Interpreters for the Deaf Quality Assurance Test Georgia (GA) Georgia Assessments for the Certification of Educators (GACE) Basic Skills Assessment Reading Mathematics Writing Content Assessments American Sign Language Art Education Birth Through Five Biology Early Childhood Education Early Childhood Special Education General Curriculum English Mathematics Middle Grades Language Arts Middle Grades Mathematics Middle Grades Reading Reading School Psychology Special Education Academic Content Concentrations Special Education Adapted Curriculum Special Education Deaf Education Special Education General Curriculum Professional Pedagogy Assessment Educational Leadership Assessment Paraprofessional Assessment Illinois (IL) Assessment of Professional Teaching (APT) Early Childhood (Birth to Grade 3) Elementary (K-9) Secondary (6-12) Special (K-12) or (P-21) Content-Area Tests Director of Special Education Early Childhood Education Early Childhood Special Education Elementary/Middle Grades English Language Arts Learning Behavior Specialist I Mathematics Reading Specialist Reading Teacher School Psychology School Social Worker Special Education General Curriculum test Speech-Language Pathologist: Nonteaching Speech-Language Pathologist: Teaching Teaching of Students Who Are Blind or Visually Impaired Teaching of Students Who Are Deaf or Hard of Hearing Learning Behavior Specialist II (LBS II) Tests Behavior Intervention Specialist Bilingual Special Education Specialist Curriculum Adaptation Specialist Deaf-Blind Specialist Multiple Disabilities Specialist Technology Specialist Transition Specialist Massachusetts (MA) Massachusetts Test for Educator Licensure (MTEL) Communication and Literacy Skills test Academic (PreK–12) subject matter tests Early Childhood English Foundations of Reading General Curriculum Mathematics Mathematics (Elementary) Mathematics (Middle School) Middle School Humanities Reading Specialist Vocational Technical Literacy Skills Test Adult Basic Education test Michigan (MI) Michigan Test For Teacher Certification (MTTC) Autism Spectrum Disorder Basic Skills Behavioral Studies Bilingual Education Biology Chemistry Cognitive Impairment Communication Arts (Secondary) Early Childhood Education Earth/Space Science Elementary Education Emotional Impairment English English as a Second Language Fine Arts Guidance Counselor Health Health, Physical Education, and Recreation Hearing Impaired History Humanities Integrated Science (Elementary) Integrated Science (Secondary) Language Arts (Elementary) Learning Disabilities Mathematics (Elementary) Mathematics (Secondary) Middle Level Music Music Education Physical Education Physical or Other Health Impairment Physical Science Physics Psychology Reading Reading Specialist Social Studies Speech and Language Impaired Visual Arts Education Visually Impaired Minnesota (MN) Minnesota Teacher Licensure Examinations (MTEL) Basic Skills Pedagogy: Early Childhood (Birth to Grade 3) Pedagogy: Elementary (Grades K-6) Pedagogy: Secondary (Grades 5-12) Content Area Tests: Early Childhood Education (Birth to Grade 3) Content Area Tests: Elementary Education (Grades K-6) Content Area Tests: Mathematics (Grades 5-12) Content Area Tests: PrePrimary (Age 3 to PreKindergarten) Content Area Tests: Reading Teacher Content Area Tests: Special Education Core Skills (Birth to Age 21) Nebraska (NE) Nebraska Commission for the Deaf and Hard of Hearing Quality Assurance Screening Test (QAST) New Mexico (NM) New Mexico Assessment of Teacher Basic Skills New Mexico Assessment of Teacher Competency (Elementary OR Secondary) New Mexico Content Knowledge Assessment in Special Education New York (NY) New York State Teacher Certification Examinations (NYSTCE) Liberal Arts and Science Test (LAST) Assessment of Teaching Skills (ATS-W) Elementary Secondary Bilingual Education Assessment (BEA) Content Specialty Tests (CSTs) American Sign Language Biology Blind and Visually Impaired Chemistry Deaf and Hard of Hearing Earth Science English Language Arts English to Speakers of Other Languages (ESOL) Health Education Literacy Mathematics Multi-Subject Music Physical Education Physics Social Studies Students with Disabilities Theatre Visual Arts Communication and Quantitative Skills Test (CQST) Assessment of Teaching Skills-Performance (ATS-P) Oklahoma (OK) Oklahoma General Education Test (OGET) Oklahoma Professional Teaching Examination (OPTE) Oklahoma Subject Area Tests (OSAT) Advanced Mathematics Art Biological Sciences Blind/Visual Impairment Chemistry Deaf/Hard of Hearing Early Childhood Education Earth Science Elementary Education Subtest 1: Reading/Language Arts Elementary Education Subtest 2: Social Studies/Mathematics/Science/Health, Fitness and the Arts Elementary Principal Specialty Test English English as a Second Language Instrumental/General Music Middle Level English Middle Level/Intermediate Mathematics Middle Level Principal Specialty Test Middle Level Science Middle Level Social Studies Mild-Moderate Disabilities Physical Education/Health/Safety Physical Science Physics Reading Specialist School Counselor School Psychologist Secondary Principal Specialty Test Severe-Profound/Multiple Disabilities Speech-Language Pathologist U.S. History/Oklahoma History/Government/Economics Vocal/General Music World History/Geography Oregon (OR) Oregon Educator Licensure Assessments (ORELA) Administrator Art Biology Chemistry Early Childhood Education English Language Arts English to Speakers of Other Languages (ESOL) Health Mathematics Middle Grades English Language Arts Middle Grades General Science Middle Grades Mathematics Middle Grades Social Studies Multiple Subjects Music Physics Physical Education Protecting Student and Civil Rights in the Educational Environment School Counselor Special Education Texas (TX) Texas Examinations of Educator Standards (TExES) Principal Pedagogy and Professional Responsibilities 4-8 Generalist 4-8 English Language Arts and Reading/Social Studies 4-8 Mathematics/Science 4-8 Mathematics 4-8 Science 4-8 English Language Arts and Reading 4-8 Social Studies 4-8 English as a Second Language (ESL)/Generalist 4-8 Pedagogy and Professional Responsibilities 8-12 English Language Arts and Reading 8-12 Social Studies 8-12 History 8-12 Mathematics 8-12 Science 8-12 Physical Science 8-12 Life Science 8-12 Chemistry 8-12 Mathematics/Physics 8-12 Reading Specialist School Counselor Educational Diagnostician English as a Second Language (ESL) Supplemental Health EC-12 Physical Education EC-12 Pedagogy and Professional Responsibilities EC-12 Special Education Supplemental Bilingual Education Supplemental Mathematics/Physical Science/Engineering Music EC-12 Art EC-12 Deaf and Hard of Hearing Visually Impaired/Braille American Sign Language Bilingual Target Language Proficiency Test (BTLPT) Bilingual Target Language Proficiency Test (BTLPT) Supplemental Guide Generalist EC-6 Bilingual Generalist EC-6 English as a Second Language (ESL)/Generalist EC-6 Pedagogy and Professional Responsibilities EC-6 Texas Assessment of Sign Communications (TASC) Texas Assessment of Sign Communications-American Sign Language (TASC-ASL) Virginia (VA) Virginia Communication and Literacy Assessment (VCLA) Virginia Quality Assurance Screening (VQAS) Virginia Reading Assessment (VRA) Early/Primary prek-3 Elementary Education prek-6 Special Education-General Curriculum Special Education-Hearing Impairments Special Education-Visual Impairments Washington (WA) Washington Educator Skills Test-Basic (WEST-B) Mathematics Reading Writing Washington Educator Skills Test-Endorsements (WEST-E) Bilingual Education Biology Chemistry Dance Earth and Space Science Early Childhood Education Early Childhood Special Education Elementary Education English Language Arts English Language Learner Health/Fitness History Mathematics Middle Level Humanities Middle Level Math Middle Level Science Music: Choral Music: General (neither Choral nor Instrumental) Music: Instrumental Physics Reading Science Social Studies Special Education Visual Arts Other Specify _________________________
Other test	Other Specify _________________________

1 Allow Postal Code if State = Outside the U.S.; Display Country Field

2 An alternate contact is an individual who will always know where the scholar is residing.

3 Allow Postal Code if State = Outside the U.S.; Display Country Field