Indian Education Professional Development Grants Program: GPRA and Service Payback Data Collection

OMB Control Number: 1810-0698

Expiration: XX/XX/XXXX

Indian Education Professional Development Program

Data Collection System

Employment Verification Form

OMB Control Number: 1810-0698

Expiration: XX/XX/XXXX

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. The valid OMB control number for this collection is 1810-0698. Public reporting burden for this collection of information is estimated to average 10 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 retain benefit per Title VI of the Elementary and Secondary Education Act, 20 USC §7442, and its corresponding regulations at 34 CFR Part 263. If you have any comments concerning the accuracy of the time estimate, suggestions for improving this individual collection, or if you have comments or concerns regarding the status of your individual form, application or survey, please contact Linda Brake, Education Program Specialist, Office of Indian Education, U.S. Department of Education, 400 Maryland Ave SW, Room 3W248, Washington, DC 20202 or email Linda.Brake@ed.gov directly.

Rules of Behavior for Department of Education-Sponsored Website

The Indian Education Professional Development Program Data Collection System (PDPDCS) is an online data collection system designed to facilitate administration of the Indian Education PDP. This system collects employment and contact information from participants to verify the fulfillment of their service payback requirement. 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 PDPDCS must agree to certain conditions and agree to act to insure the accuracy and confidentiality of the information stored by the PDPDCS.

Violation of this policy will result in suspension of employer access to the PDPDCS.

Employers using this system agree to:

• Maintain requested participant information, and

• Maintain PDPDCS accounts established to collect grant, participant, and employer information by:

• Submitting accurate information for the participants’ employment status and employer information; and

• Using the PDPDCS only to access their own information.

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

□ I agree to the terms.

Employment Verification Page 1

Welcome to the Indian Education Professional Development Program Data Collection System (PDPDCS). The program participant listed below accepted funds from a grant awarded to an Institution of Higher Education (IHE) or Tribal College or University (TCU) by the Department of Education’s Indian Education Professional Development Program (PDP). In receiving funds, the participant agreed to a service payback requirement. Participants are required to provide PDPDCS with updates about their employment every 6 months in order for PDPDCS to track the fulfillment of their service payback obligation. Additional information about PDPDCS and the service payback is available on the PDPDCS Web site at https://pdp.ed.gov/oie.

Please take a moment to verify the accuracy or to correct any inaccuracies of the information provided by the participant. We anticipate that the survey will take no longer than 10 minutes to complete.

Your session will timeout after 30 minutes of inactivity and the information entered will not be saved.

Do NOT use your internet browser's back button during this process. Thank you for taking the time to provide this information!

Employee Name: [PRE-FILLED]

* Required fields necessary to submit a record. [ALL FIELDS ARE PRE-FILLED BASED ON PARTICIPANT’S RESPONSES. EMPLOYERS MAY EDIT FIELDS AS NECESSARY]

Employer Information

*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:

_________________ __________________

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

__________________________________

Supervisor Information

*First: *Last:

___________________________ __________________________

Supervisor’s Business Address

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ __________________

*E-mail: *Verify E-mail:

_________________ ________________

Alternate E-mail Address: Verify Alt. E-mail:

_________________ ___________________

Fax:

_____________________

Human Resource Manager

*First: *Last:

___________________________ __________________________

Human Resource Manager’s Business Address: 

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ __________________

*E-mail: *Verify E-mail:

_________________ ________________

Alternate E-mail Address: Verify Alt. E-mail:

_________________ ___________________

Fax:

_____________________

Name of person completing this form

_______________________________

Employment Verification Page 2

Please review the information below.

If you AGREE with the participant’s responses, please check the “Agree” box beside the question. If you DISAGREE with the participant's response to a particular question, please check the “Disagree” box beside the question. Once you have indicated “Agree” or “Disagree” to all the questions, click the Submit” button at the bottom of the page. You will have an opportunity to describe the reason for your disagreement on the following page. An Employment Dispute Report will be provided to the participant and he or she will have the opportunity to review your changes, revise responses as needed and resubmit the record for verification.

Employee Name: [PRE-FILLED]

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

Participant Answer:

• General Education Teacher

• Special Education Teacher

• Native Language Teacher (not classified as a classroom teacher)

• Assistant Principal

• Principal

• Administrator – LEA (Local Education Agency)

• Administrator – SEA (State Education Agency)

• Administrator – TEA (Tribal Education Agency) Agree □Disagree □

*2. Was the participant employed in this position between DATE [DISPLAY EMPLOYMENT START DATE] to DATE [IF CURRENT EMPLOYMENT, DISPLAY DATE PARTICIPANT SUBMITTED RECORD. IF PAST EMPLOYMENT, DISPLAY EMPLOYMENT END DATE]? (mm/dd/yyyy)

Agree □ Disagree □

*3. Is/was this full time or part time employment?

Participant Answer: Agree □ Disagree □

*4. [DISPLAY ONLY IF EMPLOYMENT IS PART TIME] If this employment is part-time, on average, how many hours do you work per week at this job?

Participant Answer: Agree □ Disagree □

*6. Please select the most appropriate grade span (check all that apply)

Participant Answer: Agree □ Disagree □

•  Pre-K

•  K – 5

•  6 – 8

•  9 – 12

•  Other (please specify) ____________________

*7. What area(s) of education best describes/described this position?

Participant Answer: Agree □ Disagree □

General Area of Education

 □  Administration
 □  Elementary Education

 □  Secondary Education

 □  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) __________

*8. Which of the following describes the teaching certificate you currently hold that certifies you to teach in this state?

Participant Answer: Agree □ Disagree □

• Regular or standard state certificate or advanced professional certificate content area may be special education or the grade level

• Certificate issued after satisfying all requirements except the completion of a probationary period (in some states this is called a probationary certificate)

• Certificate that requires some additional coursework, student teaching, or passage of a test before regular certification can be obtained (in some states this is called a temporary or provisional certificate)

• Certificate issued to persons who must complete a certification program in order to continue teaching (in some states this is called a waiver or emergency certificate)

• I do not hold any of the above certifications.

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

If you checked DISAGREE next to any of the participant’s responses, please describe the reason for your disagreement on the following page. Please include what you believe to be the correct response. An Employment Dispute Report will be provided to the participant and he or she will have the opportunity to review your changes, revise responses as needed and resubmit the record for verification.

Page 1 26460.1