1. SECTION I – PARTICIPANT INFORMATION
  2. SECTION II – INSERVICE INFORMATION
  3. SECTION III – PARTICIPANT AFFIDAVIT
  4. SECTION IV – ATTENDANCE VERIFICATION
    1. SECTION V – APPROVAL OF CLOCK HOUR FOR SALARY PLACEMENT
          1. Revised 10/29/03


       

              		 

      CONTINUING EDUCATION

      CLOCK HOUR REQUEST

       

      INSERVICE REGISTRATION


       

      Use this form to verify your attendance at an approved clock hour offering outlined in Section II below. The individual as verification of attendance must retain this form. It is the individual’s responsibility to maintain accurate records with certification regulations. DO NOT USE THIS FORM IF YOU WILL RECEIVE COLLEGE CREDIT FOR THIS INSERVICE PROGRAM. PLEASE PRINT LEGIBLY AND USE PEN ONLY.

       

      SECTION I – PARTICIPANT INFORMATION
      Legal Name (Last, First, M.I.)

              		Classified    

      Certificated           		Former Name
      Your School Location

               		Current Assignment Date of Birth WA Certificate No
      (Optional)

        Female

        Male
      Home address (street, city, state, zip code)

              		Home Phone:  (  )

       

      Work Phone:  (  )

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      SECTION II – INSERVICE INFORMATION
      Title of Inservice

              		Instructor’s Name
      Maximum Clock Hours Available

               		First Date of Inservice:

                		Last Date of Inservice:

         
      Sponsoring Provider Name (Agency Granting Clock Hours) & Address

      Everett School District No 2, 4730 Colby Ave/PO Box 2098, Everett, WA 98213       		Business Telephone Number

      (425) 385-4086

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      SECTION III – PARTICIPANT AFFIDAVIT
       

      I,  , swear/affirm that I have earned          clock hours for actual attendance at this inservice. I am not applying for college/university credit for this program. Also, I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. The intentional misrepresentation of a material fact in this form subjects the holder to revocation of his/her certificate pursuant to chapter 180-85 WAC. The holder for possible dispute (WAC 180-85-085) should retain this form.

       

           

      Original Signature of Participant  Date Signed


      The content of an approved program offering for continuing education hours earned after September 1, 1995 must meet criteria established by the State Legislature. At the time credits are recognized by the school district, the content of the course must meet at least one of the following criterion. Please mark all that apply.
      „ 1. It is consistent with a school-based plan for mastery of student learning goals as referenced in the annual school performance report for the school in which the individual is assigned.
      „ 2. It pertains to the individual’s current assignment or expected assignment for the following school year.
      „ 3. It is necessary for obtaining an endorsement as prescribed by the State Board of Education.
      „ 4. It is specifically required for obtaining advanced levels of certification.
      „ 5. It is included in a college or university degree program that pertains to the individual’s current assignment or potential future assignment as a certificated instructional staff of the school district, where the potential of the future assignment is agreed upon by the school district and the individual.
       

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      SECTION IV – ATTENDANCE VERIFICATION
       

      When signed by the approved inservice provider, this form serves as a transcript or letter documenting eligible credits as required for salary purposes by WAC 392-121-280 (2).

       

           

      Original Signature of Instructor or Designee  Date Signed





      SECTION V – APPROVAL OF CLOCK HOUR FOR SALARY PLACEMENT
       

      I certify this is true and correct to the best of my knowledge.

       

      Employee Signature    Date  

       

      Principal/Supervisor Signature    Date    Approved: _____YES _____NO




      Revised 10/29/03



       

       

      Instructions for Completing Clock Hour Request

       


       
      Æ Sign in on attendance sheet. Hours indicated in Section III must match attendance record. Clock hours will not be recorded unless participant completes attendance record.
       
      Æ Complete Inservice Evaluation Form
       
      Æ Fill in Sections I, II, and III of Inservice Registration Form
       
      Æ Instructor signs Section IV verifying attendance and hours received.
       
      Æ For clock hours to be documented in your personnel file for salary advancement, please have your principal/supervisor sign Section V of this form and send to Human Resources.
       
      Æ An Approval of College and Clock Hour Credit for Salary Advancement Form must accompany Out-of-District clock hour forms. (It is no longer needed for In-District clock hours.)
       
      Æ It is recommended you keep a copy of this form for your records
       

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