Fill and Sign the Gsa 3689 Employees Service Agreement for Receipt of a Relocation Incentive Form

Initial Trainer Approval Application for Organizations May 11, 2010 Organization Information (Application must be typed) Name of Organization: Complete Mailing Address: Website: Business or Tax ID Number: Type of Business � Non-profit � For profit Is this organization licensed to do business in DC? Training Delivery Method � Yes � No � In person � Web-based instruction � DVD or CD instruction � Other platform: What will training participants receive after completing training? � Clock Hours � Continuing Education Units (CEUs) � International Association for Continuing Education & Training (IACET) Accredited � CEUs delivered via partnership with: (college/university) Attachments: � I have enclosed a copy of the organization’s business or tax ID number Primary Contact Information Name of Primary Contact: Title/Position: Telephone Number: Email Address: Training Level Organization Wide Select the level for which you are applying � Basic � Intermediate � Advanced Specialized Field Is your organization representing a specialized field with trainers who do not have early childhood/child development degree or experience? � No � Yes, the field is: What Core Knowledge Area(s) is your Organization Seeking Approval For? Select the Core Knowledge Area(s) � Child Growth and Development � Health, Safety, and Nutrition � Curriculum � Inclusive Practices � Learning Environments � Observing, Documenting and Assessing to Support Young Children and Families � Building Family and Community Relationship � Diversity: Family, Language, Culture, and Society � Program Management, Operation and Evaluation � Professionalism and Advocacy � Social-Emotional Development and Mental Health Office of the State Superintendent of Education – Division of Early Childhood Education Electronic Submissions: Please scan application with all attachments as one (1) document and email as directed. Initial Approval Application for Organizations Additional Organization-Level Certifications (for informational purpose only; example: Maryland approved trainer, Red Cross certified instructor, etc.) Certification Type Certifying Agency or State Expiration Date Evidence of Policy Alignment Organizations must demonstrate that their policy for hiring DC trainers meets all of the initial and ongoing trainer approval requirements as stated in the Trainer Approval Program Policy and Procedures Manual. Do you have evidence on file that the trainers* listed in this application meet the requirements for the level and core knowledge area your organization is seeking approval in? � Yes � No Attachments: � I have enclosed a copy of the organization’s policy and procedures for hiring trainers* � I have enclosed a copy of the organization’s trainer* application form (blank) � I have enclosed a copy of the organization’s trainer* application form (completed copy from a current trainer’s file) *For distance education program, trainer refers to curriculum developer or training facilitator. Office of the State Superintendent of Education – Division of Early Childhood Education Electronic Submissions: Please scan application with all attachments as one (1) document and email as directed. Initial Approval Application for Organizations Current List of Trainers Eligible to Conduct Trainings in DC (trainers conducting trainings in DC must meet all ECE trainer approval requirements) Trainer Core Knowledge Area(s) Level 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Trainers Demographics (for informational purpose only) Total Number of Trainers Eligible to Conduct Trainings in DC: List Total Number of Trainers in Each Category Gender: [ ] Female Trainers [ ] Male Trainers Ethnic Origin/Race: Hispanic Origin [ [ [ [ [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] ] ] ] ] [ ] Yes [ ] No American Indian or Alaska Native Asian Indian Black or African American White Chinese Filipino Japanese Korean Native Hawaiian/Pacific Islander Other Asian: Other Pacific Islander Vietnamese Other: Language: Do your trainers speak a language other than English? � No � Yes, we have trainers that speak the following language(s): Office of the State Superintendent of Education – Division of Early Childhood Education Electronic Submissions: Please scan application with all attachments as one (1) document and email as directed. Initial Approval Application for Organizations Sample Training Module (complete for each core knowledge area and at the highest training content level you are seeking; please refer to module evaluation rubric in Trainer Approval Manual to understand how the module will be evaluated) Title of Training: __________________________________ Length of Training: _____________________ Core Knowledge Area: ______________________________ Level: � Basic � Intermediate � Advanced Target Audience: check all that apply [ ] Before/After School Age Program Staff [ ] Staff Working with 0-2 Year Olds [ ] Staff Working with 2-4 Year Olds [ ] Staff Working with 4-5 Year Olds rd [ ] Staff Working with K – 3 Graders [ ] Other (please specify): [ ] Early Intervention/Special Education Staff [ ] Program Administrators Brief Description of Training: Three Major Training Outcomes: At the end of this training, the learner will be able to: 1. 2. 3. Learning Opportunities and Training Pace: (must aligned with training outcomes, depth to content/Bloom’s Taxonomy, core knowledge areas) Activity / Learning Opportunities Length of Activity Goal of this Activity Office of the State Superintendent of Education – Division of Early Childhood Education Electronic Submissions: Please scan application with all attachments as one (1) document and email as directed. Initial Approval Application for Organizations Methods of Delivery: How will training engage auditory learners? How will training engage kinesthetic learners? How will training engage visual learners? References/Resources: What scholarly resources are used to support the training content? (minimum 3 within the past 10 years) Title Source Name of Source Author Date Type of Source If this is an intermediate and advanced level training, please include pre-test and post-test. If this is an advanced level training, please include action plan or follow-up activity. Office of the State Superintendent of Education – Division of Early Childhood Education Electronic Submissions: Please scan application with all attachments as one (1) document and email as directed. Initial Approval Application for Organizations Organization References Name of Reference Title/Affiliation Relationship to Applying Organization Phone Number Email Address 1. 2. Confirmation of Eligibility I attest that the information included in this application is, to the best of my knowledge, true and accurate. If approved as a training organization, we will deliver trainings at the training level and in the core knowledge areas in which we have been approved. I have evidence on file that the trainers listed in this application, at minimum, meet the requirements for the training level and in the core knowledge area(s) our organization is seeking approval in. I have read the Trainer Approval Program Policy and Procedures Manual and will uphold the Guiding Principles of this program. I understand that approval as a training organization through this application process is not equivalent to a certification, and does not guarantee employment. ________________________ Signature of Applicant Date: Submission Procedures Applications must be received (not postmarked) via mail or email by the due date. Email Applications to: diane.mason@dc.gov Mail Applications to: Diane Mason Division of Early Childhood Education Office of the State Superintendent of Education th 810 First Street NE, 4 Floor Washington, DC 20002 (202) 727-8118 Office of the State Superintendent of Education – Division of Early Childhood Education Electronic Submissions: Please scan application with all attachments as one (1) document and email as directed.