Fillable !80-02! EDUCATOR EFFECTIVENESS DEPARTMENT OUT-OF-STATEAPPROVED PROGRAM AND COMPLETION (Illinois State Board of Education)

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!80-02! EDUCATOR EFFECTIVENESS DEPARTMENT OUT-OF-STATEAPPROVED PROGRAM AND COMPLETION (Illinois State Board of Education)

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ISBE 80-02 (12/21)
Page 1 of 3
PART I of VII – TO BE COMPLETED BY APPLICANT
An applicant applying for an Illinois license who has completed a state-approved program of preparation at a college or university shall
use this form to verify completion of the program and coursework addressing specic Illinois standards. The applicant should provide
all information requested in Part I of this form, and the college/university should complete the rest of the form as applicable. Please
request that the college/university e-mail the completed form to licensureforms@isbe.net. Forms returned to the applicant or Regional
Oce of Education will not be honored.
APPLICANT'S NAME (Last, First, Middle, Maiden) IEIN BIRTHDATE (mm/dd/yyyy)
ADDRESS (Street, City, State, Zip Code) TELEPHONE (Include Area Code)
E-MAIL
NAME OF COLLEGE/UNIVERSITY
ADDRESS (Street, City, State, Zip Code) TELEPHONE (Include Area Code)
!80-02!
100 North First Street, E-240
Springeld, Illinois 62777-0001
OUT-OF-STATE–APPROVED PROGRAM AND
COMPLETION OF STANDARDS VERIFICATION
EDUCATOR EFFECTIVENESS DEPARTMENT
PART II OF VII – TO BE COMPLETED ONLY BY THE COLLEGE/UNIVERSITY
DIRECTIONS: Please complete the information below, date it, and ax the signature of the licensure ocer, the registrar, or the dean
of the college of education. Then, e-mail this form to the Illinois State Board of Education at licensureforms@isbe.net. Forms returned
to the educator will not be honored. If this form is being lled out for an Illinois University, please use Form 80-09.
NAME OF COLLEGE/UNIVERSITY TELEPHONE (Include Area Code) FAX (Include Area Code)
NAME AND TITLE OF AUTHORIZED OFFICIAL E-MAIL
YES NO I certify that the information provided below is true and correct.
Signature of Authorized Date
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ISBE 80-02 (12/21)
Page 2 of 3
PART IV of VII – TO BE COMPLETED ONLY BY THE COLLEGE/UNIVERSITY
COMPLETION OF ILLINOIS STANDARDS VERIFICATION: Please verify that the above-named applicant has completed
coursework addressing the standards listed below (further explanation addressed in Part 25.25(a)). Standards can be met by the
applicant having completed coursework in each specific area or if the content coursework was infused within the completed program.
If the standards have already been met, the educator will not be required to complete additional coursework. Proceed to Part V to
verify successful completion of testing for licensure.
Yes No
Methods of instruction of the exceptional child in cross-categorical special education
Course Number/Title:________________________________________ Date Completed: _______________________
Methods of reading and reading in the content area
Course Number/Title:________________________________________ Date Completed: _______________________
Instructional strategies for English language learners
Course Number/Title:________________________________________ Date Completed: _______________________
TYPE OF LICENSE / AREAS THE EDUCATOR IS PREPARED TO TEACH
TEACHING
LICENSE
ADMINISTRATIVE
LICENSE
_______________________________
Age or Grade Level
General Administrative (Principal)
_______________________________
Grade Level
Superintendent
_______________________________
Grade Level
Chief School Business Ocial
_______________________________
Teaching Fields
Director of Special Education
_______________________________
Grade Level and/or Teaching Field(s)
_______________________________
_______________________________
_______________________________
Grade Level and/or Teaching Field(s)
the educator was preparted to teac
PART III OF VII– TO BE COMPLETED ONLY BY THE COLLEGE/UNIVERSITY
STATE-APPROVED PROGRAM VERIFICATION: Please verify that the above-named applicant has completed your state-
approved program of preparation that, in your state, qualies the educator for licensure comparable to the specic types
listed below. The registrar, licensure ocer, or other authorized ocial should certify the information below. Proceed to Part
IV to verify completion of coursework addressing Illinois Standards.
Early Childhood
(Birth-Grade 2)
Elementary (1-6)
Middle Grades (5-8)
Secondary (6-12)
Special (K-12 or K-22)
Other
ISBE 80-02 (12/21)
Page 3 of 3
PART VI OF VII – TO BE COMPLETED ONLY BY THE COLLEGE/UNIVERSITY
Eective February 1, 2012, all professional education and content-area coursework required for the issuance of an Illinois license,
endorsement or approval must have been passed with a grade of no lower than a “C-” or equivalent. Grades of “P” (Passing) or “S”
(Satisfactory) cannot be honored for licensure until verication is provided by the licensure ocer, the registrar, or the dean of the
college of education that these grades are equivalent to a “C-” or above.
MARK ONE OR MORE OF THE CHOICES BELOW:
P (PASSING), S (SATISFACTORY) or CR (CREDIT) GRADES ARE EQUIVALENT TO A "C-" OR ABOVE.
P (PASSING) OR S (SATISFACTORY) GRADES ARE EQUIVALENT TO A “D" OR BELOW
ADDITIONAL COMMENTS:
PART VII OF VII – TO BE COMPLETED ONLY BY THE COLLEGE/UNIVERSITY
DIRECTIONS: Please verify that the above-named applicant has completed student teaching as part of the state approved
preparation program.
YES NO I certify that the applicant has completed student teaching as part of the state approved preparation program.
Course Number/Title:________________________________________ Date Completed: _______________________
YES NO If YES, was student teaching completed prior to September 1, 2015?
PART V of VII – TO BE COMPLETED ONLY BY THE COLLEGE/UNIVERSITY
CONTENT AREA TEST(S) – required by the state of ____________________________ for issuance of a license.
Specific to content area of licensure.
Name of Test: _____________________________________ Date Passed: _______________________
TEACHER PERFORMANCE ASSESSMENT - A performance based assessment that requires candidates to submit
a portfolio of materials (such as video clips and lesson plans) demonstrating skills and knowledge essential for
teaching. (EX.- edTPA, PPAT)
Name of Test: _____________________________________ Date Passed: _______________________
(The edTPA can be waived for educators who completed their program in the Spring of 2020 through Fall of 2022.)
Date/Semester program completed: _______________________
NO TESTS WERE TAKEN AS PART OF THIS PROGRAM
(The student teaching or internship can be waived for educators who completed their program in the Spring or Summer of 2020.)
TESTING VERIFICATION: Please verify that the above named applicant has successfully passed
the following test(s) that led to
licensure in your state.
If the applicant did not receive licensure in your state, the Board of Education in the state in which he/she is currently licensed must
provide verification of the test used for licensure purposes (via ISBE Form 80-03A Confirmation of Out-of-State Licensure Testing.
(e.g. Educator completed preparation program at an Iowa institution and obtains Iowa licensure - use this form. An educator who
completed a program in Iowa, does not obtain Iowa licensure, but obtains licensure in Missouri, should use ISBE Form 80-03A (5/17).
Please send copies of score reports to
licensureforms@isbe.net
.. . .
I have reviewed the information above and certify that the person named in Part I passed the following test(s) (check all that apply):
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80-02 EDUCATOR EFFECTIVENESS DEPARTMENT OUT-OF-STATEAPPROVED PROGRAM AND COMPLETION (Illinois State Board of Education)

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Completed 25 April 2022

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