UND Credit Approval Form

Professional Development for Educators

Credit Approval Form

To apply for professional development credit approval from the University of North Dakota, please submit the required information at least 1 month prior to the start of the educational activity.

* = Required Information

Instructor of Record
The instructor of record is the individual designated to ensure the integrity of the professional development offering as an academically rigorous graduate-level activity. The instructor of record’s role, as an active participant in the activity, is to ensure submission of: 1) this credit approval form; 2) syllabus and presenter information (as described below); 3) the evaluation plan for determining the participant’s grade (use criteria identified in the “Evaluation Plan Criteria” section below); and 4) final grades.
*First Name:
*Last Name:
*Highest Degree Earned
(must have a Master’s degree or above):
*Field of Study
(i.e. Education, Social Work):
Title:
*Organization/School:
*Work Address:
*City:
*State:
*Zip:
*Daytime Phone:
*E-mail:
Yes, I have been an instructor of record for previously approved courses/workshops through UND Professional Development for Educators. (Must provide updated résumé every 3 years.)
No, I have NOT been an instructor of record for previously approved courses/workshops through UND Professional Development for Educators.
Please attach your current vita/résumé that outlines your educational background and professional work experience related to the subject matter of this activity.
Please check if you seek employment to teach as a temporary UND adjunct faculty member.
Instructor of Record (Continued)
If your summer contact information is not the same as above, please list:
Address:
City:
State:
Zip:
Daytime Phone:
E-mail:
Contact Person
If the contact person is other than the instructor of record, please list below.
First Name:
Last Name:
Title:
Organization/School:
Work Address:
City:
State:
Zip:
Daytime Phone:
E-mail:
Information About the Course, Workshop, or Conference
*Name of Sponsoring Agency, Organization or School:
*Title of Activity:
Has this activity previously been approved for professional development credit through UND Professional Development for Educators?
/ Yes
No
*Maximum Number of Participants:
*Target Audiences
Check no more than 2 audiences.
/ K-12
Early Childhood Education
Elementary School
Middle School
High School
*Topic Areas
Check no more than 3 topic areas.
/ Administration/Leadership Language Arts
Art & Theatre Math & Science
Career & Technology Education Music
Classroom Management Social Sciences
Counseling Special Education/Special Needs
Instructional Strategies Technology
Life Skills/Social Issues
2-Sentence Description for Summer Catalog
*required for workshops held between May 1 and August 30
/ Market your activity by briefly describing (30 words or less) why educators should attend. Highlight learning objectives using action verbs.
*Facility Name:
Room:
Street Address:
*City:
/
*State:
*Day 1: Date Start Time End Time
*Day 2: Date Start Time End Time
*Day 3: Date Start Time End Time
*Day 4: Date Start Time End Time
*Day 5: Date Start Time End Time
*Will this same activity be offered in additional location(s)? / Yes. Please indicate above or attach separate sheet with the location, dates, and times for all additional locations.
No
Credits
One credit is awarded for every 15 hours of direct instructional time. Time for meals, breaks, exhibits, and any other non-instructional activities should not be included.
*Number of Credits Requested: / 1 2 3 4
*Grading Format: / Satisfactory/Unsatisfactory (S/U)
Letter Grade (A-F)
Both A-F and S/U
Attach Letter Grade Assessment Rubric.
Below are online resources to help you develop assessment rubrics:
·  http://www.uwstout.edu/soe/profdev/rubrics.shtml#cooperative
·  http://edtech.kennesaw.edu/intech/rubrics.htm
·  http://www.cyberspaces.net/6traits/rubric2.html
Credit Approval is Requested Through: / Art (ART 900)
Counseling (COUN 900)
Geography (GEOG 900)
Instructional Systems & Business Ed (ISBE 900)
Music (MUSC 900)
Teaching & Learning (T&L 900)
Other: please list:
Syllabus Information
Please attach a complete syllabus for your activity.
Your syllabus must include the following elements:
1. Overall Description or Purpose of Activity
Please describe your activity in a way that is appealing to your audience, is concise (75 words or less), and explains the benefits participants will receive by attending. This longer description will be published on UND Professional Development for Educators’ website.
2. Overall Learning Objectives/Participant Outcomes
o  What are participants accountable to know and be able to do at the conclusion of activity?
o  How will participants be asked to apply the knowledge?
3. Agenda with Time Schedule, Presenter(s), & Session Description(s)
NOTE: If the program or marketing materials for your activity include the following information, you may attach it as your agenda.
A.  Include the beginning and ending times for each instructional activity/session.
One credit is awarded for every 15 hours of direct instructional time. Time for meals, breaks, exhibits, and any other non-instructional activities should not be included.
B.  Outline/describe the topics and content areas covered in each instructional activity/session.
C.  If your activity has multiple speakers, list the presenters for each instructional activity/session and their educational credentials.
Presenters are strongly encouraged to possess master’s degrees or higher, but bachelor’s degrees may be accepted based on level of experience, accomplishments, and subject matter expertise. For multi-speaker activities, 75% of the total instructional time must be provided by presenters with master’s degrees or higher.
4. Evaluation Plan Criteria
The evaluation plan for determining the participant’s grade must be submitted as part of your syllabus. The evaluation plan may be formatted in a number of ways, but it must include how you will:
A.  Verify participant attendance at all instructional activities/sessions required for the credit. You may use session sign-in sheets, session summaries, or other methods that document participation in at least 15 hours of instructional activities.
B.  Determine if the learning objectives/student outcomes have been successfully met. An assignment, such as a lesson plan, summary paper, or group project/paper, should demonstrate each participant’s ability to apply the concepts/knowledge learned at the activity to their own teaching/work situations.
Fees & Registration
A $50 recording fee will be collected for each professional development credit. This fee is in addition to any other conference/course fees. The University of North Dakota will provide a secured online registration form that processes the credit recording fee(s) via credit card or check.
*Is this activity restricted or limited to local school districts and/or consortiums? / Yes. Please list the school districts and/or consortiums eligible to participate in the teacher training:
No
*Will you charge participants a course/workshop registration and/or supply fee in addition to UND’s credit recording fee ($50 per credit)? / Yes. Please specify:
No
Please list applicable registration information as it should be published in marketing materials.
Contact Person:
Organization:
Phone:
E-mail:
Web:
Pre-registration Deadline:
Submission
Signature:
Date:

Submit the UND Credit Approval Form at least 1 month prior to start of your activity by:

E-mail: (Subject Line: Credit Approval)

Mail: UND Professional Development for Educators

Attn: Credit Approval

Gustafson Hall – Room 103

3264 Campus Road, Stop 9021

Grand Forks, ND 58202-9021

Fax: 701.777.6401

We will notify you of approval or disapproval of professional development credit within 2 weeks. If your activity is approved, you will receive further information about our online credit registration process.

If you have any questions, please feel to contact us at 701-777-4225 or .

Thank you!

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Current as of 1/6/2009