RSA PIMS Grantee Scholar Record

Grantee Reporting Form -Rehabilitation Services Administration (RSA) Annual Payback Report

RSA PIMS Grantee Scholar Record 1820-0617 rev 11-2018

Grantees: Scholar Record

OMB: 1820-0617

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1820-0617 can be found here:

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Rehabilitation Services Administration (RSA) Payback Information Management System (PIMS)

Scholar Record

(Completed by Grantee)

OMB Control Number: 1820-0617

Expiration:

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 mandatory per the Rehabilitation Act of 1973, as amended (Rehabilitation Act) and its associated regulations 34 CFR 386.40. 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 1820-0617. Note: Please do not return the completed Scholar Record to this address.

Rules of Behavior for U.S. Department of Education-Sponsored Website

The Rehabilitation Services Administration (RSA) Payback Information Management System (PIMS) is an online data collection system designed to facilitate administration of the Rehabilitation Long-Term Training (RLTT) Program, in the Rehabilitation Services Administration, Training Programs Unit at the U.S. Department of Education. This system collects contact information, educational training, funding, and employment from participating scholars to verify the fulfillment of their service obligation and assess program performance. Verifying service obligation requires collecting personally identifying information from universities, scholars, and employers. This data collection has been authorized by the Rehabilitation Act of 1973, as amended (Rehabilitation Act) and the Government Performance and Results Act of 1993, section 4.

Users of the PIMS must agree to certain conditions and agree to act to insure the accuracy and confidentiality of the information stored by the PIMS.

Violation of this policy will result in suspension of grantee access to the PIMS. Users representing grantees agree to:

Maintain requested grant information, including grant contact information;
Maintain PIMS accounts established to collect grantee and scholar information by:
- Protecting account login names and passwords;
- Submitting scholar information as requested by PIMS;
- Reviewing scholar information for accuracy; and
- Protecting the confidentiality of personally identifying information requested by PIMS.

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

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 about the scholar is the Rehabilitation Act of 1973, as amended (Rehabilitation Act). We request the scholar’s educational information pertinent to the RLTT scholarship grant received whether provided by the scholar, grantee, or other entity, including personally identifiable information (PII), under this authority in order to accurately track the scholar’s records and to differentiate the scholar’s financial obligation from other scholars who may have the same name. The scholar’s participation in the RLTT Program is voluntary, but you must provide the requested information, including the scholar’s PII, in order for the student to participate in the RLTT Program. The information will be used to ensure that recipients of scholarships provided with funds under the Rehabilitation Act meet specific statutory and regulatory requirements, including service obligation fulfillment or repayment of financial obligation.

The information in the scholar’s 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.

□ I agree to the terms.

Rehabilitation Services Administration (RSA) Payback Information Management System (PIMS)

Grantee Instructions for the Scholar Record

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

Entering Scholars: Please note that scholars may only be entered into the PIMS under one RSA RLTT grant at a time. If a scholar is funded sequentially under multiple RLTT funded grants, please exit the scholar from the first RLTT grant and assure that the scholar completes the Exit Certification from that RLTT grant. Then, the scholar and grantee must submit a new Payback Agreement under the next RLTT grant from which the scholar will receive funds. Please contact the PIMS Help Desk at 1-800-832-8142 or send an email to rsascholars@ed.gov for further information, if needed.

System Timing Out: You will be logged out of the system if you do not click the Save for Later or Save and Submit button after 30 minutes.

Saving and Submitting Records: To save a record for future editing or completion, click on the Save for Later button. This will create a pending record. When you have completed entry for a scholar, check the box in Section J. Then, click on the Save and Submit button. When the record is “submitted” for a scholar who has exited or completed the program, it CANNOT be edited. To edit those submitted records, please contact the Help Desk. However, records submitted for currently enrolled scholars can be edited.

Scholar Access to System: Scholars are given access to the system when their records are submitted. If they have exited the training program they are eligible to begin fulfilling their service obligation per Program Regulations: §386.40(a)(7).

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
Do not use a university email address.
*Verify Primary E-mail Address

Alternative E-mail Address

Verify Alternative E-mail Address

* Required fields necessary to submit a record.

B. Contact Information
Permanent Address

*Address

Address Line 2

*City	*State	*Zip Code

*Home Phone	Cell Phone


Secondary Address

Address

Address Line 2

City	State	Zip Code

Other Phone	Fax

C. Alternate Contact Information

Address and contact information for a relative or other person through which PIMS may contact the scholar, if necessary.

First Name

Last Name

E-mail Address

Verify E-mail Address

Address

Address Line 2

City

State

Zip Code

Home Phone

Other Phone

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.

□ No changes necessary.

D. Payback Agreement

Please upload a copy of the completed and signed Payback Agreement for this scholar.

*Date scholar signed the Payback Agreement: __________

DO NOT upload blank or unsigned agreements.

Files cannot exceed 6 MB in total between the files uploaded in Section D, Section E, and Section I. If the files are larger than 6 MB in total, please compress the files or alter the scanning resolution. For best results, please ensure the scanner is set to a resolution of no larger than 300 dpi and "Black & White" or "Grayscale" is set. Several compression tools are available, including PDF Optimizer for those users who have Adobe Acrobat 7 or later. Depending on the size of the file, the upload process may take several minutes. Acceptable file types include .doc, .docx, and .pdf. For assistance please contact the Help Desk at 1-800-832-8142 or send an email to rsascholars@ed.gov.

E. Scholar Demographic Information

What is this scholar’s gender?

Female
Male
Transgender

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

Hispanic or Latino
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Does this scholar have a disability?

Yes
- What is the scholar’s disability?_____________
- When was the onset of the scholar’s disability? ____________
No
Unknown

What is this scholar’s current age?

Under 21
21-29
30-39
40-49
50-59
60 and over

*Has this scholar received funding under a different RLTT grant?

Yes (Please specify grant number _________________________)
No

*Is this scholar is a U.S. citizen or national, or a permanent resident of the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, American Samoa, or the Commonwealth of the Northern Mariana Islands?

*Is the scholar a lawful permanent resident of the United States or in the United States for other than a temporary purpose with the intention of becoming a citizen or permanent resident?

*Does this scholar have the capacity to complete this course of study leading to a

degree?

*Has this scholar expressed an interest in a career in clinical practice, administration, supervision, teaching, or research in the vocational rehabilitation, supported employment, or independent living rehabilitation of individuals with disabilities, especially individuals with significant disabilities in the field of study in which the training will be received?

*Is this scholar capable of being employed, once the scholar completes the program?

*Please upload the scholar’s Certification of Eligibility for Federal Assistance in Certain Programs (ED 80-0016). (Click here to download a blank Certification of Eligibility for Federal Assistance in Certain Programs)

Please upload documentation verifying proof of U.S. citizenship or legal permanent resident status (e.g., copy of driver’s license, Passport, social security card).

F. Current Training Program Information

*1. Date scholar enrolled in the RLTT program: __________ (mm/dd/yyyy)

Please provide the date the scholar enrolled in the RLTT program, which may or may not have been the date the scholar began receiving funding through the grant.

*2. Date scholar began receiving funding through the RLTT program: __________ (mm/dd/yyyy)

*3. Check the degree(s) or certificate the scholar is pursuing through this training grant: (Check all that apply)

Bachelor’s degree
Master’s degree
Doctoral degree
Certificate

Please review and verify the information in Section F Items 1 through 3. Check the box below if there have been no changes in the last year.

□ No changes necessary.

Note: Section F, Items 4, 5, and 6 must be completed annually for scholars until they exit or graduate. Please complete these items for each year the scholar was actively enrolled in the program, even if he/she did not receive funding through the grant that year. A scholar is considered actively enrolled in the program if the scholar is working toward the degree/certificate your RSA RLTT grant was designed to support. An actively enrolled scholar should be taking courses, completing an internship, working on a dissertation, or performing other similar activities required for completion.

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

Budget Period	Full-time scholar, even if the scholar worked full-time or part-time	Part-time scholar (anything less than full-time)	Not enrolled in the program
[PRELOAD DATES FY 1]	Full-time scholar	Part-time scholar	Not enrolled in the program
[PRELOAD DATES FY 2]	Full-time scholar	Part-time scholar	Not enrolled in the program
[PRELOAD DATES FY 3]	Full-time scholar	Part-time scholar	Not enrolled in the program
[PRELOAD DATES FY 4]	Full-time scholar	Part-time scholar	Not enrolled in the program
[PRELOAD DATES FY 5]	Full-time scholar	Part-time scholar	Not enrolled in the program
[PRELOAD DATES NCE 1]	Full-time scholar	Part-time scholar	Not enrolled in the program
[PRELOAD DATES NCE 2]	Full-time scholar	Part-time scholar	Not enrolled in the program

*5. Specify the total amount of funding this scholar received directly from this RSA RLTT supported training grant during the current budget period. In calculating the total amount, include any student stipends, tuition and fees, books and supplies, and student travel in conjunction with training assignments. Please enter $0 for a scholar who was enrolled in the grant program but did not receive funding during the current budget period.

Budget Period	Scholar Funding Amount
[PRELOAD DATES FY 1]	$
[PRELOAD DATES FY 2]	$
[PRELOAD DATES FY 3]	$
[PRELOAD DATES FY 4]	$
[PRELOAD DATES FY 5]	$
[PRELOAD DATES NCE 1]	$
[PRELOAD DATES NCE 2]	$
Total	$[SUM ABOVE]

*6. During the current or most recent grant budget period, was this scholar employed in a qualified position in the field of vocational rehabilitation?

Budget Period	Employment Information
[PRELOAD DATES Year 1]	Employed: Yes	No	Not enrolled in the program
[PRELOAD DATES Year 2]	Employed: Yes	No	Not enrolled in the program
[PRELOAD DATES Year 3]	Employed: Yes	No	Not enrolled in the program
[PRELOAD DATES Year 4]	Employed: Yes	No	Not enrolled in the program
[PRELOAD DATES Year 5]	Employed: Yes	No	Not enrolled in the program
[PRELOAD DATES NCE 1]	Employed: Yes	No	Not enrolled in the program
[PRELOAD DATES NCE 2 ]	Employed: Yes	No	Not enrolled in the program

G. Scholar Status

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

1. *Scholar program status:
Select the most appropriate option below.

○ The scholar is still enrolled in the program and is currently receiving RLTT funding.

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

Please specify reason scholar is no longer receiving RLTT funding but is still enrolled.

___________________________________________________________

○ The scholar exited/graduated the program.

Please enter the date of exit/graduation.

__________ (mm/dd/yyyy)

Please note: The Exit Certification must be completed, signed and uploaded into PIMS within 30 days of exit/graduation from the program.

○ The scholar exited without graduating/completing the program.

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

Did the scholar complete one academic year or more in duration?

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

□	Transferred to another program in the field of rehabilitation counseling
□	Transferred to another program of study
□	Financial stress or burden
□	Health (physical/emotional) of self or family member
□	Moved
□	Obtained employment
□	Other personal reasons
□	Expulsion due to poor academic performance
□	Poor practicum/field-based performance
□	RSA grant closed

Please note: The Exit Certification must be completed, signed and uploaded into PIMS within 30 days of exit from the program.

2. * Accumulated academic years of funding:
Enter durations less than one academic year as decimals. For example, 0.5 is half of one academic year of funding. See FAQ 4, for more information on accumulated academic years of funding.

3. Total service obligation in months: (prepopulated by the PIMS)

This amount was calculated by multiplying accumulated academic years of funding by 24 months, i.e., two years of service obligation for every academic year of scholarship support equals 24 months.

4. Date by which service obligation must be completed: (prepopulated by the PIMS)

This date was calculated by adding the total service obligation (accumulated academic years of funding multiplied by 24 months, i.e., two years of service obligation for every academic year of scholarship support) and the additional two years to the date to complete or exit the training.

H. Scholar Exit Information

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

Bachelor’s degree
Master’s degree
Doctoral degree
Certificate

*2. Did the scholar complete an internship as part of this RSA grant-supported training?

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

Yes (If selected, go to question 3)
No (If selected, go to Section I)
Don’t know (If selected, Section I)

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

Certified Rehabilitation Counselor (CRC) exam
State exam
Other ________________

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

Yes
No
Not applicable, our state does not set a passing score.

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

Yes (If selected, repeat questions 3 to 5 until no other measures, up to 5 total)
No (If selected, go to Section I)

I. Service Obligation Information and Exit Certification

Please upload a copy of the completed and signed Exit Certification for this scholar within 30 days of exit from the program (either prior to completion or at completion of program).

DO NOT upload blank or unsigned agreements.

J. Information Verification

Saving and Submitting Records: To save a record for future editing or completion, click on the Save for Later button. This will create a pending record. When you have completed entry for a scholar, check the box below. Then, click on the Save and Submit button. Secondary Users cannot submit scholar records. Only Project Directors can submit scholar records. When the record is “submitted,” for a scholar who has exited or completed the program, it CANNOT be edited. To edit those submitted records, please contact the Help Desk. However, records submitted for currently enrolled scholars can be edited.

□ Yes, all information available for this scholar has been entered. I certify that all of the information I have provided is true and correct to the best of my knowledge. I understand that if I purposely give false or misleading information, I may be fined in an amount not less than $5,000 and not greater than $10,000, plus 3 times the amount of damages the Government sustains due to my false statement. - False Claims Act, 31 USC § 3729.

Verification of Eligible Scholar Employment

Scholars are required to provide PIMS with annual updates about their employment in order for PIMS to track the fulfillment of their service obligation. For scholars to receive service obligation credit, it is incumbent upon you to review the information provided and determine if the scholar’s employment is eligible for payback consistent with the program regulations.

1. Employer Information (fields are pre-filled)

Name of Employer: ______________________________

Department: ________________________________

Organization Address

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Fax:

_________________ ___________________

TTY:

_____________________

Organization’s Web site address: __________________________________

2. Employer organization type: (prefilled with scholar’s response)

3. Scholar’s job title: (prefilled with scholar’s response)

4. Scholar’s duties: (prefilled with scholar’s response)

Is this employment eligible for service obligation?

Yes, I approve
No, I disapprove
- If no, describe why not._____________________________

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Mark Partridge
File Modified	0000-00-00
File Created	2021-01-20