Fillable ACRReviewFormDraft090618 - ACR Review Form Draft 030415

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ACRReviewFormDraft090618 - 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 us t!attach !ap pro priate!
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mustattachappropriate
thirdpartydocumentationtotheCreditFacultyCredentialsApplication.AcoverlettershouldbepreparedbytheDeanthatprovidesarationalefortheteaching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:
Alternative
Credentialing Chair
Print Name:
Alternative
Credentialing Chair
Signature: Date:
Campus President
Print Name:
Campus President
Signature: Date
To be completed by
the Collegewide Alternative Credentialing Committee Chair:
Additional Information Request
Please resubmit with the following items:
Darren Smith
Alternative Credentialing (AC) Review Based on
Other Documented Qualifications
* This applicant does not explicitly meet degree and course work guidelines, but has been recommended for a teaching assignment based
on an Alternative Credentialing (AC) Review of other documented qualifications.
Name of
Faculty*:
VID:
(if available)
Division:
Campus:
Dean/Director:
Date:
Teaching
Discipline:
Please check one: ☐Full Time ☐Part time
Explanation:
Dean/Director
Signature:
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Completed 13 May 2020

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