This form is to be submitted with each request for clock hours to the local continuing education committee

according to rules established by the diocesan CEU committee. Duplicate this form as needed.

File Folder # / Name:
School: / City:
Licenses Held: / License Expiration Date:
Date: / Email:

Title/Experience:______

Date:______# Clock Hours Requested______

REQUESTINGAPPROVALFOR:CEU Credits Pre-approval (form will be sent to you if it is pre-approved)

SELECTCATEGORY:

A B C D* E* F1* F2* F3* G1* G2* G3* H1* H2* I1*, ** I2*, **

* Maximum of 30 clock hours. ** Must be pre-approved. See back of page for details regarding categories.

SELECTREQUIREMENT – we are only able to apply one requirement per approval application

Positivebehaviorinterventionstrategies

Accommodation,modification,adaptationofcurriculum, materials, etc.forstandards

Furtherreadingpreparation*(MNStatute122A.06,Subd.4.)

Key warningsigns of early-onsetmental illnessin childrenand adolescents

Suicide Prevention

Integrationoftechnology withstudent learning toincrease engagement and achievement*

Reflective statementofprofessionalaccomplishmentassessment of professional growth*

English Language Learners

* SchoolNurses,counselors,psychologists,socialworkers,audiovisualdirectors/coordinators,and recreationalpersonnelareexempt.

Describe how you incorporated this into your classroom:______

______

______

______

Please include objective, amount of time engaged, and an evaluation of the experience. Attach additional documentation/explanation and detail as appropriate.

For use by Diocese of Winona CEU committee.

Approvedfor clock hoursMaximumreachedin categoryMaximumreachedfor licensure

Pre-approvedto I1 (travel) and I2 (work experience)- When submitting forfinal approval,attachthis endorsedpre-approval form.

Not Approved: No verification Notwithin5-year block Max reachedin categoryorlicensure other

CommitteeSignature:______Date:______
Definition. “Clockhour”means anhourofactualinstruction,or planned group orindividualprofessional developmentactivityas

approvedbythelocalcontinuing education/relicensurecommittee.

Categoriesforclock hourallocation. Verification ofcompletion ofexperiencesmustbesubmitted by the applicant tothelocalcommittee.Clockhoursmustbe earnedin two or more of thecategories in itemsA toI:

A.relevantcourseworkcompletedat accreditedcollegesanduniversities;

(1quartercredit= 16ClockHours, 1semestercredit= 24ClockHours -- Maximum: 124 clockhoursinafive-yearblock.)

B.educationalworkshops,conferences,institutes,seminars,orlecturesin areasappropriateto licenses held

(1hourofparticipation= 1 ClockHour -- Maximum: 124 clockhoursinafive-yearblock.)

C.staffdevelopmentactivities,inservicemeetings,andcourses;doesnotinclude regular facultymeetingsor beginning of year workshop hours

(1hourofparticipation= 1 ClockHour -- Maximum: 124 clockhoursinafive-yearblock.)

D.site,district,regional,state,national,orinternationalcurriculumdevelopment

(1hourofparticipation= 1 ClockHour-- Maximumof30ClockHours)

E.engagementin formalpeercoachingormentorshiprelationshipswithcolleaguesthataddressesoneor moreofthestandardsin part8710.2000;(1 hourofparticipation=1ClockHour-- Maximumof30ClockHours)

F.professionalserviceinthefollowingareas:

(1)supervisionofclinicalexperiencesofpersonsenrolledinteacherpreparationprograms;

(1quarter= 16ClockHours, 1 semester=24ClockHours -- Maximumof30ClockHours)

(2)participationonnational,state,andlocalcommitteesinvolvedwithlicensure,teachereducation,or professionalstandards;(1hourofparticipation= 1 ClockHour-- Maximumof30ClockHours)

(3)participationin national,regional,orstateaccreditation;

(1hourofparticipation=1 ClockHour-- Maximumof30ClockHours)

G.leadershipexperiencesinthefollowingareas:

(1)developmentof neworbroaderskillsand sensitivitiestotheschool,community,orprofession;

(1hourofparticipation= 1 ClockHour-- Maximumof30ClockHours)

(2)publicationofprofessionalarticlesina professionaljournalinanappropriatefield

(Manuscriptrequired-- Maximumof30ClockHours)

(3) volunteerwork inprofessionalorganizationsrelatedtotheareasof licensureheld

(Maximumof30ClockHours)

H.opportunitiestoenhanceknowledgeandunderstandingofdiverseeducationalsettingsinthefollowing areas:

(1)experienceswithstudentsofanotherage,ability,culture,orsocioeconomiclevel

(1hourofparticipation= 1 ClockHour-- Maximumof30ClockHours)

(2)systematic,purposefulobservationduringvisitstoschoolsandtorelatedbusinessandindustry;

(1hourofparticipation= 1 ClockHour-- Maximumof30ClockHours)

I. preapprovedtravelor workexperience:

(1)travelforpurposesof improvinginstructionalcapabilitiesrelatedtothefieldof licensure

(1weekofpre-approvedtravel=10ClockHours;Maximum-- Maximumof30ClockHours)

(2) work experienceinbusinessor industryappropriatetothefieldof licensure

(1weekofpre-approvedworkexperience=10ClockHours-- Maximumof30ClockHours)

ReadingPreparationrequirements
Instructionandpracticein phonemicawareness
Phonicsandotherword-recognitionskills
Guidedoralreadingforbeginningreaders
Vocabularyinstruction
Instructioninfosteringandunderstandinghigher orderthinkingforallages
Readingincontentareas
Specificreadingstrategiestoimpactcomprehension
Currentresearchandbestpracticesinreading research instruction / Key WarningSignsof Early-OnsetMental
IllnessinChildrenandAdolescents
Whichmayinclude:
Depressedmood
Excessivefears& anxieties
Changesinbehavior& performance
Failuretodeveloppeerrelationships
Impairedconcentrationandthinking Suicidalgestures
Potentialconnectiontosubstanceabuse