Fillable ACRReviewFormDraft030415 - ACR Review Form Draft 030415

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ACRReviewFormDraft030415 - ACR Review Form Draft 030415

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Note:!Applications!based!on!Alternative!Credentialing!(AC)!must!be!approved!by!the!Collegewide!Faculty!Credentials!Oversight!Committee!prior!to!the!scheduling!of!any!formal!teaching!assignments.!Faculty!m ust!a ttach !ap prop riate!
third!party!documentation!to!the!C red it!Fa culty !Cred entia ls!Ap plica tion .!A!co ver!letter!sh ou ld!be !prep ared !by!th e!Dea n!th at!pro vid es!a!ra tiona le!for!th e!teac hing!assignment!and!a!synopsis!of!the!documentation.!Subject to a 5-year
review depending upon academic discipline and Alternative Credentialing standards.!
!
Alternative Credentials
Review Request Form
Name of Faculty:
VID:
(if available)
Division:
Campus:
Dean:
Subject to a
5-year review on:
Please check one: ☐Full Time ☐Part time
EFFECTIVE
ACADEMIC
TERM
COURSES REQUESTED
Course number, title, and credit
hours. (List individually. Do not
list ALL and XXX Prefix)
TRANSFER
COURSE?
Y/N
GRANTING INSTITUTION
Include degree award date.
OTHER QUALIFICATIONS
Including, but not limited to:
Licensure, certifications,
letters of recommendations,
publications, industry-specific
documentation, etc.
LICENSURE/
CERTICIATION
EXPIRATION
DATE
COURSE
APPROVAL?
Y/N
Completed by
Alternative
Credentialing
Chair
Note:!Applications!based!on!Alternative!Credentialing!(AC)!must!be!approved!by!the!Collegewide!Faculty!Credentials!Oversight!Committee!prior!to!the!scheduling!of!any!formal!teaching!assignments.!Faculty!m ust!a ttach !ap prop riate!
third!party!documentation!to!the!C red it!Fa culty !Cred entia ls!Ap plica tion .!A!co ver!letter!sh ou ld!be !prep ared !by!th e!Dea n!th at!pro vid es!a!ra tiona le!for!th e!teac hing!assignment!and!a!synopsis!of!the!documentation.!Subject to a 5-year
review depending upon academic discipline and Alternative Credentialing standards.!
!
The faculty applicant certifies by signature below that all information provided on this form and all supporting documentation is correct and accurate to the best of his/her knowledge.
Faculty Applicant
Print Name:
Faculty Applicant
Signature:
Date:
Dean/Director
Print Name:
Dean/Director
Signature:
Date:
Campus President
Print Name:
Campus President
Signature:
Date:
Alternative
Credentialing Chair
Print Name:
Alternative
Credentialing Chair
Signature:
Date
To be completed by the Collegewide Alternative Credentialing Committee Chair:
Additional Information Request
Please resubmit with the following items:
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ACRReviewFormDraft030415 - ACR Review Form Draft 030415

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Completed 13 May 2020

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