Teacher Employment Records Form

APPENDIX C

TEACHER EMPLOYMENT RECORDS FORM

THE STUDY OF TEACHER RESIDENCY PROGRAMS (TRPs)

TEACHER EMPLOYMENT RECORDS FORM

The teacher employment records are part of the data collection for the Study of Teacher Residency Programs (TRPs), sponsored by the Institute of Education Sciences (IES) in the U.S. Department of Education. The study seeks to describe the characteristics of TRPs and their participants and mentors. We will also summarize the academic outcomes of students taught by novice TRP teachers and examine the retention rate of novice TRP teachers.

We are asking you to provide the requested information on the teachers listed in the attached form. The data collected from this form will be used to track the mobility of study teachers. If you have any questions, please contact Dr. Phil Gleason at 315-781-8495. Thank you for your time and cooperation.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collected. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: U.S. Department of Education, Institute of Education Sciences, National Center for Education Evaluation and Regional Assistance, 555 New Jersey Avenue, NW, Washington, DC 20208.

OMB NO.: xxxx-xxxx

EXPIRATION DATE: xx/xx/20xx

Please return this completed form by fax no later than DATE FAX: (XXX) XXX-XXXX, Attn: NAME HERE

District:

DISTRICT NAME

TEACHER POSITION INFORMATION

Please verify that the employment information listed below is accurate as of DATE, 2012. For each pre-populated column, please verify whether the information is “correct” or “incorrect” in the column to the right. Please note any changes to grade and subject.

Teacher Name & ID	School Name	Verify School	Grade	Verify Grade	Subject	Verify Subject
Teacher Name #1 ID: #####		□ Correct □ Incorrect		□ Correct □ Incorrect		□ Correct □ Incorrect
Teacher Name #2 ID: #####		□ Correct □ Incorrect		□ Correct □ Incorrect		□ Correct □ Incorrect

If you answered “incorrect” to any of the information provided above, please provide an explanation for the change, and the corrected information.

DISTRICT REPRESENTATIVE INFORMATION Please complete the section below.
Name (please print clearly) Title: Date:	Signature Phone number: Email:

If you have any questions, please contact NAME HERE

at (XXX) XXX-XXXX or STUDY EMAIL ADDRESS HERE

Per the policies and procedures required by the Education Sciences Reform Act of 2002, Title I, Part E, Section 183, responses to this data collection will be used only for statistical purposes. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific district or individual. We will not provide information that identifies you or your district to anyone outside the study team, except as required by law. Any willful disclosure of such information for nonstatistical purposes, without the informed consent of the respondent, is a class E felony.