Application Deadline Dates

Application Deadline Dates:

Winter Review - March 1

APPLICATION FOR EVALUATION OF WORK EXPERIENCE

In partial fulfillment of the requirements of the

Bachelor of Career and Technical Studies Degree

Submitted to:

CAREER AND TECHNOLOGY EDUCATION TEACHERS

College of Education

Science, Math, Technology Education Department

CALIFORNIA STATE UNIVERSITY, SAN BERNARDINO

5500 University Parkway

San Bernardino, CA92407

(909) 537-5679

Submitted by:

September 13, 2018

Application Deadline Dates:
Winter Review - March 1

APPLICATION FOR EVALUATION OF WORK EXPERIENCE

In partial fulfillment of the requirements of the
Bachelor of Career and Technical Studies Degree
Submitted to:
CAREER AND TECHNOLOGY EDUCATION TEACHERS
College of Education
Science, Math, Technology Education Department
CALIFORNIA STATE UNIVERSITY, SAN BERNARDINO
5500 University Parkway
San Bernardino, CA92407
(909) 537-5679
Submitted by:

On
September 13, 2018

ADVISER'S CERTIFICATION

This is to certify that , student ID number

, has been counseled by me, Donna Shea, BCTS Program Coordinator/Advisor regarding the Bachelor in Career Technical Studies Degree and work experience requirements. The candidate has met the minimum qualifications required by the California Education Code and CSU Executive Order 1036. It is my recommendation that his/her work, teaching, and professional experience, as documented in this application, be accepted toward meeting the requirements for the Bachelor of Career and Technical Studies Degree at California State University, San Bernardino.

______

Donna Shea, BCTS Program Coordinator/AdvisorDate

This is to certify that this application requesting evaluation of work experience has been reviewed by me. The candidate has met the minimum qualifications required by the California Education Code and CSU Executive Order 1036. It is my recommendation that his/her work, teaching, and professional experience, as documented in this application, be accepted toward meeting the requirements for the Bachelor of Career and Technical Studies Degree at California State University, San Bernardino and the suggested quarter units be awarded to the candidate.

RECOMMENDED AWARD: ______Quarter Units

______

Dr. Ronald Pendleton, CTE Program CoordinatorDate

______

Dr. Joe Scarcella, MA in CTE Program CoordinatorDate

______

Dr. Herb Brunkhorst, SMTE Department ChairDate

APPLICANT'S CERTIFICATION

I,certify under penalty of perjury, or after first being duly sworn, that I have provided complete and accurate responses to the items on this application. I further certify (swear) all official documents submitted in support of this application are authentic and unaltered records that pertain to me. I authorize release of any information submitted by me in connection with my application to any person, firm, corporation, association, or government agency, but only to verify or explain the information, obtain pertinent records, or in connection with perjury proceedings. My notarizedsignature certifies the accuracy and completeness of the information provided. I understand that any misrepresentation may be cause for denial by the Career and Technical Education Teachers and/or California State University at San Bernardino and expulsion from the Bachelor in Career and Technical Studies Degree Program.

______

Applicant's SignatureDate

CSU San Bernardino

Bachelor of Career and Technical Studies

EVALUATION OF EXPERIENCE

BCTS AdvisorEstimate of Points

Nancy Nurse / Allied Health

Name of Applicant Vocational Subject Field

Maximum Possible

SECTION A - Work and Supervisory Experience

Months of work experience divided by 3...... = ______(45)

Months of supervisory experience divided by 3 ...... = ______(20)

Total for Section A...... = (65)

SECTION B - Teaching Experience

Months of full-time _____ times 3 divided by 20 ...... = ______(20)

Months of part-time ______divided by 10 ...... = ______(10)

Total Total for Section B ...... = (30)

SECTION C - Professional Development

C-1 Professional Activities/Organizations...... = ______(3)

C-2 Occupational/Vocational Activities/Organizations...... = ______(3)

C-3 Professional Literature...... = ______(3)

C-4 Occupational Contacts ...... = ______(1)

C-5 Education [# hrs __ times .3] ...... = ______(15)

Total Total for Section C...... = (25)

Grand Total (Section A, B, & C) ...... = (120)

Quarter Units (Grand total divided by 4 times 1.5) ...... = (45)

Vocational/Career and Technical Courses(for which credit is not earned elsewhere). . . = ______

Recommended Units...... = (45)

Note: This is a work sheet only and does not necessarily reflectnumber of units recommended by the CTE Faculty Reviewers.

______

Donna Shea, BCTS Program Coordinator/AdvisorDate

PERSONAL INFORMATION

Nancy Nurse / 000-123-456 / Allied Health
Full Name / Student ID Number / Teaching Specialty/Industry Sector
5678 Main Street / Any town / CA 92345
Street Address / City / State Zip Code
555-555-1234 / 555-555-5678 / 555-555-7890
Home Phone / Cell Phone / FAX
United Vocational Institute / 555-555-9876 / Beth Arles, Ed. Director
Employer / Work Phone / Supervisor
2036 Emerson Place / Any town / CA 95201
Street Address / City / State Zip Code

PROFESSIONAL REFERENCES

References may be contacted regarding questions that arise during application review.

Judy Ames

/ Allied Health Instructor / 555-555-9876
Name / Title / Work Phone
2036 Emerson Place / Any town / CA 95201
Street Address / City / State Zip Code

Dr. Gerald Smith

/ Radiology Instructor / 555-555-2843
Name / Title / Work Phone
2036 Emerson Place / Any town / CA 95201
Street Address / City / State Zip Code

Robert Engalls

/ MD / 555-555-2984
Name / Title / Work Phone
9438 Center Road / Any town / CA 95393
Street Address / City / State Zip Code
SECTION “A” – WORK EXPERIENCE

WORK/SUPERVISORY EXPERIENCE

List only those jobs that correspond directly to the subject(s) indicated on your career and technical/vocational teaching credential. Start with your most recent job and work back to the first position of this kind that you held. Use as many additional pages as needed.

Employer
Methodist Hospital / Immediate Supervisor
Jane Smith, RN / Work Phone
555-555-9827
Street Address
29 Main St. / City
Any town / State Zip Code
CA 90000
Work Experience
Title/Position
Floor Supervisor / Date (from/to)
6/2000 to 6/2001 / Number of Months
12 / Hours per Week
10
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______
Title/Position
Floor Supervisor / Date (from/to)
6/1998 to 6/2000 / Number of Months
24 / Hours per Week
20
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______
Title/Position
CCU RN / Date (from/to)
1/1994 to 6/1998 / Number of Months
42 / Hours per Week
40
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______

Total Work Experience ______

Supervisory Experience
Title/Position
Floor Supervisor / Date (from/to)
6/2000 to 6/2001 / Number of Months
12 / Hours per Week
20
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______
Title/Position
Floor Supervisor / Date (from/to)
6/1998 to 6/2000 / Number of Months
24 / Hours per Week
20
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______
Title/Position / Date (from/to) / Number of Months / Hours per Week
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______

Total Supervisory Experience ______

WORK/SUPERVISORY EXPERIENCE

Employer
Doctor’s Hospital of LA / Immediate Supervisor
Kathryn Gonzales, RN Supv. / Work Phone
555-555-2984
Street Address
534 Central Ave. / City
Los Angeles / State Zip Code
CA 90101
Work Experience
Title/Position
ICU RN / Date (from/to)
1/1990 to 12/1994 / Number of Months
36 / Hours per Week
40
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______
Title/Position / Date (from/to) / Number of Months / Hours per Week
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______
Title/Position / Date (from/to) / Number of Months / Hours per Week
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______

Total Work Experience ______

Supervisory Experience
Title/Position
None / Date (from/to) / Number of Months / Hours per Week
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______
Title/Position / Date (from/to) / Number of Months / Hours per Week
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______
Title/Position / Date (from/to) / Number of Months / Hours per Week
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______

Total Supervisory Experience ______

WORK/SUPERVISORY EXPERIENCE

Employer
Nurses Registry of Covina / Immediate Supervisor
Rene Blake, Dir of HR / Work Phone
555-555-2987
Street Address
9457 Azusa Blvd. / City
Covina / State Zip Code
CA 90284
Work Experience
Title/Position
On-call Home
Health RN / Date (from/to)
1/1989 to
12-1989 incl. / Number of Months
12 / Hours per Week
36 average
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______
Title/Position / Date (from/to) / Number of Months / Hours per Week
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______
Title/Position / Date (from/to) / Number of Months / Hours per Week
Do not write in this space.
Hrs/week ______X 4.3 = ______ 172 = ______x ______mos. = ______

Total Work Experience ______

Total Supervisory Experience ______

SECTION “B” – TEACHING EXPERIENCE

TEACHING CREDENTIALS/CERTIFICATES

List all of your teaching credentials and/or certificates that you hold or have held, including clear, preliminary or expired. Begin with the most current and work backward. Include all professional licenses, certificates, diplomas, and degrees relevant to your credential

Document Subject/Industry Sector Dates
1.Designated Subjects Teaching Credential in Allied Health issued July 29, 1999.
2.Diploma dated December 1989 from United Vocational Institute verifying successful complete for the registered nursing program.
3.
4.
5.
6.
7.
8.
9.
10.

TEACHING EXPERIENCE

Start with your most current work backward. Use a separate page for each.

School/District Name
United Vocational Institute / Supervisor
Beth Arles, Ed. Director
2036 Emerson Place / Any town / CA 95201
Full-Time (Over 20 hours per week) / Do not write in this column
Dates (from/to)
6/2003 to 6/2004 / Number of Months
12 / Hours per Week
25 / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours
Part-Time (Under 20 hours per week) / Do not write in this column
Dates (from/to)
1/2002 to 1/2003 / Number of Months
12 / Hours per Week
16 / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours
Exactly 20 hours per week / Do not write in this column
Dates (from/to)
1/2003 to 6/2003 / Number of Months
6 / Hours per Week
20 / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours

TEACHING EXPERIENCE

Start with your most current work backward. Use a separate page for each.

School/District Name
Methodists Hospital / Supervisor
Jane Smith, RN
Street Address
29 Main St. / City
Any town / State Zip Code
CA 90000
Full-Time (Over 20 hours per week) / Do not write in this column
Dates (from/to)
None / Number of Months / Hours per Week / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours
Part-Time (Under 20 hours per week) / Do not write in this column
Dates (from/to)
12/2000 to 12/2001 / Number of Months
12 / Hours per Week
10 / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours
Exactly 20 hours per week / Do not write in this column
Dates (from/to)
None / Number of Months / Hours per Week / ______
Total Hours
Dates (from/to) / Number of Months / Hours per Week / ______
Total Hours
SECTION “C” - PROFESSIONAL DEVELOPMENT

C-1 PROFESSIONAL ORGANIZATIONS

List all of the professional organizations to which you belong (or have belonged to within the past three years) that are related to teaching/training.

OrganizationOffice Held or Committee Work Dates

Association of Career and Technical Member-at-large 1/90 - present

Education (ACTE)
2.
3.
4.
5.
6.
7.
8.
9.
10.

C-2 OCCUPATIONAL/VOCATIONAL ORGANIZATIONS

List all of the occupational/vocational organizations to which you belong (or have belonged to within the past three years) that are related to occupational/vocational specialty/industry sector.

OrganizationOffice Held or Committee Work Dates
1. American Nurses Association Member-at-large 1/90 - present
(ANA)
2.
3.
4.
5.
6.
7.
8.
9.
10.

C-3 LITERATURE/RESEARCH

List activities such as writing an article, planning a conference, revising a manual, or any activity that has contributed to your professional growth.

Description of Article or ActivityDates
1. RN Curriculum Revision Committee 1/87 - 12/89
United Vocational Institute
2. ICU Material Data Sheet Manual 3/1992
Doctor's Hospital of LA
3.
4.
5.
6.
7.
8.
9.
10.

C-4 OCCUPATIONAL CONTACTS

List ways in which you have kept current in your field such as trade advisory committees, on-site visitations, and subscriptions to journals or magazines.

Person and Position or Description of ActivityDates
1. United Vocational Institute Advisory Board 1/03 - 6/04
United Vocational Institute
2. Subscription to ANA Journal 1/90 - present
3. John Alder, MD 7/88 - present
4.
5.
6.
7.
8.
9.
10.

C-5 OCCUPATIONAL DEVELOPMENT

List informal training (in-service and workshops) you have taken during the past five years, that has contributed to your professional growth. Do not list college coursework shown on transcripts.

Description of Training Hours/CEUsDates
1. American Nurses Association 16 annually 1999 thru
Annual Recertification Convention 2004
2. American Heart Association 16 annually 1999 thru
Annual ACLS Recertification 2004
3. United Vocational Institute 18 hours 1/02 - 6/04
Monthly In-service workshops

CAPS Test Writing Workshop 4 hours 6/2003

5.
6.
7.
8.
9.
10.
TOTAL HOURS______
SECTION “D” – TRANSCRIPTS

TRANSCRIPTS

Place one set of unofficial transcripts for each post-secondary institution attended, including occupational, vocational, and career and technical institutions.

PAWS dated March 2005 from CSUSB verifying 24 units of EVOC course completed towards the BVE degree.

Transcripts dated June 1995 from Valley Community College verifying 72 credit units and completion of an AA degree meeting lower division general education requirements.

Diploma dated December 1989 from United Vocational Institute verifying successful complete for the registered nursing program.