RSA PIMS Employment Verification Record

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

Employment Verification Record

(Completed by Employer)

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 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 voluntary. 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 Employment Verification 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.

Employers using this system agree to:

• Maintain the confidentiality of requested employment information about scholars;

• Maintain control of secure links by adhering to workplace security safeguards; and

• Verify scholar employment within 30 days of the annual notification e-mail from PIMS.

□ I agree to the terms.

Employment Verification Page 1

Welcome to the Rehabilitation Services Administration (RSA) Payback Information Management System (PIMS). The scholar listed below accepted a scholarship from a grant awarded to a university by the U.S. Department of Education, Rehabilitation Services Administration (RSA), Training Programs Unit. Acceptance of the scholarship includes a service obligation requirement of two years of eligible employment for each year of financial support. 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, their employment must be verified by an employer. Additional information about PIMS and the service obligation is available on the PIMS website at https://pdp.ed.gov/RSA.

Please take a moment to verify the accuracy or to correct any inaccuracies of the information provided by the scholar. 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: 

Employer Information (fields are pre-filled)

*Employer’s Name: ______________________________

Department : ________________________________

Employer’s Address

*Address Line 1: Address Line 2:

___________________________ __________________________

*City: *State: *Zip Code:

________________ ___________ ______-____

*Phone: Fax:

_________________ ___________________

TTY:

_____________________

Please provide the Employer’s website address and ensure it includes the prefix http:// or https://.

__________________________________

Supervisor Information

*First Name: *Last Name:

___________________________ __________________________

Supervisor’s Business Address

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ ___________________

*E-mail: *Verify E-mail:

_________________ ________________

Alternative E-mail: Verify Alternative E-mail:

_________________ ___________________

Fax: TTY:

_____________________ _____________________

Human Resource Official Information

*First Name: *Last Name:

___________________________ __________________________

Human Resource Official’s Business Address: 

Address Line 1: Address Line 2:

___________________________ __________________________

City: State: Zip Code:

________________ ___________ ______-____

Phone: Mobile Phone:

_________________ ___________________

*E-mail: *Verify E-mail:

_________________ ________________

Alternative E-mail: Verify Alternative E-mail:

_________________ ___________________

Fax: TTY:

_____________________ _____________________

Title and name of person completing this form:

______________________________

Employment Verification Page 2.

Please review the information below.

Please select whether you AGREE or DISAGREE with the scholar's response to each question, then click the Submit button at the bottom of the page. If you disagree with the scholar’s response to any question, you will have the opportunity to describe the reason for your disagreement on the following page. An Employment Dispute Report will be sent to the scholar, and he or she will have the opportunity to revise and resubmit the employment information for verification based on your changes.

Employee Name: 

1. What type of organization is this?

Scholar Answer:

Agree □ Disagree □

I f you disagree, please explain:

2. Was the scholar employed from _______________ to ____________?

Agree □ Disagree □

If you disagree, please explain:

PLEASE NOTE: We understand that scholars may have begun employment prior to the date listed here. However, according to program regulations, scholars may begin work in eligible employment once the scholar exits or graduates. Therefore, the date indicated above reflects only that employment that began after the scholar’s exit or graduation from his/her program of study. Please verify that the scholar was employed during the dates listed above.

3. What is the scholar’s job title?

Scholar Answer:

Agree □ Disagree □

I f you disagree, please explain:

4. Description of scholar’s duties.

Scholar Answer:

Agree □ Disagree □

I f you disagree, please explain:

You may also upload a description of the scholar’s duties. Click here to upload a document.

5a. Is/was this full time or part time employment (Full time as defined by you the employer and must be 35 hours or more per week)?

S cholar Answer:

Agree □ Disagree □

I f you disagree, please explain:

5b. If this employment is/was part-time, on average, how many hours does the scholar work per week at this job?

Scholar Answer:

Agree □ Disagree □

I f you disagree, please explain

Question 6 is confidential and will not be shared with the scholar.

6. At this time, would you rate the scholar’s level of effectiveness in ensuring clients are placed in competitive integrated employment as:

• Effective

• Less than effective

• Ineffective

• Not rated for this position

• Choose not to respond

If you checked DISAGREE next to any of the scholar’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 scholar, and he or

she will have the opportunity to revise and resubmit the employment information for verification based on your changes.

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.

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