Application for Placement on the

Assessment Only Route for QTS

TITLE: National Insurance Number:

FORENAME:

SURNAME:

PREVIOUS SURNAME/S:

Date/s from – to:

ADDRESS:

Home Phone: Mobile Phone:

Email Address:

D.O.B: Teacher Reference Number

If known

GENDER: NATIONALITY:

ETHNICITY: DISABILITY:

Optional Optional

Subject:

(If Secondary)

Key Stages for Assessment: Please circle

EY/KS1 KS1/2 KS2 KS2/3 KS3/4 KS4/5

(ages 3-7) (ages 5-11) (ages 7-11) (ages 7-14) (ages 11-16) (ages 14-19)

How did you hear about the AO Programme?

GCSE or equivalent qualifications

Please give details of the following GCSE or equivalent overseas* qualifications and when they were obtained. All candidates for the AO route must have attained the standard required for GCSE grade C in English and Mathematics and if Primary, Science.

Subject / Qualification and awarding body or details of overseas equivalency * / Grade / Date of award
m / m / y / y
English
Mathematics
Science

A levels, Masters, or equivalent qualifications:

Subject / Qualification/Awarding body/Other form of assessment / Grade / Date of award
m / m / y / y

Higher education

AO candidates must have a UK degree or overseas equivalent*. In all cases a candidate's previous education should provide suitable foundation for teaching their chosen subject(s) and age range. Secondary AO candidates should normally have at least 50% of their degree in the subject(s) they are to teach.

Institution of study
Degree-awarding body (if different)
Country of study
Title of course
Main subject / Percentage of course: %
Subsidiary subjects / Percentage of course: %
Percentage of course: %
Percentage of course: %
Percentage of course: %
What percentage of the degree covers your specialist teaching subject? / %
Qualification obtained / Degree
Class / First [ ] Upper second [ ]
Lower Second [ ] Third [ ]
m / m / y / y / m / m / y / y / m / m / y / y
Date of study from / to / Date of Award

*  Qualifications other than those achieved in the United Kingdom will need to have NARIC evidence which must be attached to this application.

Information about the school where the AO candidate works

Name of school
Address
Town or city
Postcode
Telephone: / E-mail:
DfES number / / / LA
At the last Ofsted Inspection was the school graded as
“Requires Improvement or Inadequate” Yes/No
If yes, please provide evidence from the Ofsted report that your age range/department was recognised as being successful by Ofsted.
Name of School Contact:
School Contact Email:
The AO route requires you to have taught with whole class responsibility in two schools for a minimum of two years full time equivalent in total. This means that you will have been planning, teaching and assessing classes. Please provide details below to demonstrate clearly how you have met this (working with withdraw groups, individuals or short term supply teaching cannot be included).
School / Date of Contract / %fte** / Role / Whole class responsibility?
From / To / Yes / No

** %FTE = full time equivalent, ie full time contract 100%, three days per week 60%.

We require written confirmation of your teaching in one school other than the one in which you are now employed. This can be a reference that was written by the school to your current employer, or a letter of confirmation from the current Headteacher specifically for this purpose. An original should accompany your application (should you wish for this to be returned, please enclose an SAE).

Have you been employed full-time in the British Army, Royal Air Force or Royal Navy

in the past five years? Yes / No

Please complete below a pen portrait (do not exceed this page) that describes the circumstances that led you to become an instructor. Also include the reasons that you feel this is the appropriate route for you, explaining why you do not need a full training programme. Please include details of any relevant professional development that you have undertaken.

Please attach a copy of your current teaching timetable and a recent lesson observation report.

The employer of the Assessment Only candidate should read the Partnership Agreement before completing this section. If the Assessment Only candidate’s employer is a body other than a school, the body which will have the main day-to-day management responsibility for the Assessment Only teacher should fill it in.
I confirm on behalf of : (employing body)
that : (candidate name)
Is working as a teacher. I have viewed their current valid CRB/DBS disclosure form and am satisfied that there are no unexplained gaps in dates.
The employing body agrees to pay the initial, non-refundable sum of £400 per candidate for the selection visit. An invoice will be raised by Suffolk County Council on receipt of the completed paperwork. After this has been checked by the Accredited Provider’s Office and the Assessor has undertaken the selection and initial visit, a further invoice will be raised by Suffolk County Council for £2,250 if the candidate is selected for the AO Route to QTS.
Signed Headteacher/Employer: Date / /

Print name:
Title:

Candidate

(a) The information about my qualifications and experience in this application is true;

(b) I agree to prepare myself for assessment as agreed and present myself for assessment at the agreed time;

(c) I agree that the information in this application and any agreed preparation plan may be made available to any External Assessor.

(f) I do not already have Qualified Teacher Status.

Signed Date: / /

FOR BOTH SUFFOLK AND NORFOLK APPLICATIONS PLEASE RETURN THE COMPLETED FORM TO: AO Administrator, SCITT Salaried Office, Norwich Professional Development Centre,

144 Woodside Road, Norwich NR7 9QL.

AO Application Form: 14/09/2016: Page Number: 5