DoDEA Form 5013 Department of Defense Education Activity (DoDEA) Schools

CUI (When Filled In)

DEPARTMENT OF DEFENSE EDUCATION ACTIVITY (DoDEA) SCHOOLS
VERIFICATION OF PROFESSIONAL EDUCATOR EMPLOYMENT
FOR SALARY RATING PURPOSES

OMB No.: 0704-0370
OMB approval expires:

The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center
Drive, Alexandria, VA 22350-3100 (0704-0370). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO REQUESTOR IN A SEALED
ENVELOPE.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Section 2164; 20 U.S.C. Sections 902, 903, and 921-932; and E.O. 9397 SSN, as amended.
PRINCIPAL PURPOSE(S): Section I of this form provides applicant consent to obtain personal pay and employment information from former employers. The
information applicant supplies, and that the former employer supplies in Section II will be used to verify applicant employment history to determine creditable
previous experience for pay setting purposes. Information is covered by OPM/GOVT-5, "Recruiting Examining and Placement Records," https://www.opm.gov/
information-management/privacy-policy/sorn/opm-sorn-govt-5-recruiting-examining-and-placement-records.pdf. Upon entry into Federal service the form is
maintained under OPM/GOVT-1, "General Personnel Records," https://www.opm.gov/information-management/privacy-policy/sorn/opm-sorn-govt-1-generalpersonnel-records.pdf.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, the information may be
disclosed outside the DoD pursuant to 5 U.S.C. 552a(b)(3). To disclose to appropriate Federal officials pertinent workforce information for use in national or
homeland security emergency/disaster response. Additional routine uses are listed in the applicable System of Records Notice: OPM/GOVT-1, General
Personnel Records at: https://www.opm.gov/information-management/privacy-policy/sorn/opm-sorn-govt-1-general-personnel-records.pdf.
DISCLOSURE: Voluntary; however, failure to provide the requested information may delay or prevent the processing of an application for a teaching position.

SECTION I - APPLICANT DATA
1. NAME (Last, First, Middle Initial)

2. SSN

3. FORMER SCHOOL/PLACE OF EMPLOYMENT

D R A F T

4. POSITION TITLE (Teacher, Counselor, Administrator, etc.)
6. ACADEMIC LEVEL (X one)
a. ELEMENTARY

5. FORMER SCHOOL/PLACE OF EMPLOYMENT ADDRESS
(Street, City, State, and Zip Code)

c. SENIOR HIGH
d. VOCATIONAL HIGH

b. JUNIOR HIGH
7. SIGNATURE OF APPLICANT

e. COLLEGE
8. DATE SIGNED (YYYYMMDD)

SECTION II - EMPLOYMENT DATA
The above named individual is an applicant, or has been selected for employment with the Department of Defense Education Activity (DoDEA)
Schools. The data you provide will be used to establish the pay for the above named person. The information you provide, including identity, will be
disclosed to the above named person, and to other Federal, State and local agencies, at his or her request, or as otherwise authorized by the Privacy
Act of 1974, as amended, 5 U.S.C. 552a. Your completion of this form is voluntary. However, delay or failure to complete the form may delay the
processing of the applicant's application for employment.
If employee was paid for the entire month at the beginning and end of service, use those dates instead of the dates when school was in session. If
there was a break in service, indicate each period of employment separately. It is necessary that we have the specific day as well as the month and
year. Your assistance in completing this form is appreciated. Please return it as soon as possible to the applicant in a sealed envelope.
9. DATES OF EMPLOYMENT
a. FROM (YYYYMMDD) TO (YYYYMMDD)

b. FROM (YYYYMMDD)

10. APPLICANT WAS EMPLOYED (X one)
a. FULL
TIME

TO (YYYYMMDD)

c. FROM (YYYYMMDD)

TO (YYYYMMDD)

11. ADDRESS (Street, City, State, and Zip Code)

b. PART TIME (Enter number of
periods or hours per week)

12. LENGTH OF SCHOOL YEAR (Specify in months)
13. TYPED OR PRINTED NAME OF EMPLOYER (Last, First, Middle Initial)

14. TITLE

15. EMPLOYER SIGNATURE

16. DATE SIGNED (YYYYMMDD)

NOTE: No salary credit can be awarded for the following:
1. Intermittent Substitute Teaching
2. Student Teaching

DoDEA Form 5013, MONTH YEAR

3. Tutoring
4. Teacher aide or other paraprofessional experience
PREVIOUS EDITIONS ARE OBSOLETE.

Controlled By: DoDEA
Category: PERS
LDC: CHRA
POC: HR Policy & Compliance Branch