Fillable Classroom Teachers and Pupil Personnel Services Professionals (New York State Education Department)

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Classroom Teachers and Pupil Personnel Services Professionals (New York State Education Department)

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The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of Teaching Initiatives
www.highered.nysed.gov/tcert
Verification of Paid Experience Form for
Classroom Teachers and Pupil Personnel Services Professionals
This form must be completed and submitted by one of the following individuals: Superintendent, Superintendent’s
designee, Director of Human Resources, Chief School Officer of the approved non-public/independent school, or in the
case of Speech and Language Disabilities or Students with Disabilities experience only, the authorized official listed for the
approved contracting agency.
To verify classroom teaching experience, New York State employers with access to TEACH should enter a Superintendent
Statement onto the TEACH Online System instead of this form. All pupil personnel service experience must be submitted
via this form.
Instructions
The form must be completed and submitted by the employer and must be sent to the Office of Teaching Initiatives via
email to otiexpverif@nysed.gov . The Office of Teaching Initiatives will not accept the form if it is sent by the applicant.
It is suggested that the employer provide the certificate holder with a copy of this completed form for his/her records.
If the applicant is/was employed via contract with a public school district as a Speech and Language Disabilities or
Students with Disabilities teacher, the employer must submit a copy of the contract with the public school district in
addition to this form.
When completing the form, include the position (subject/title) and specific grade(s) taught for each year of employment.
• Examples of acceptable entries: Childhood Education – grade 5, Earth Science – grades 7-9, Students with
Disabilities/Special Education – Pre-Kindergarten. Acceptable teaching experience would be within the
grade/age level range of the certificate title sought.
•
Examples of unacceptable entries: “teacher”, “science teacher”, or wording that does not clearly identify the
position or subject taught (e.g., abbreviations, acronyms); “middle school”, “high school”, or wording that does
not clearly identify the specific grade(s) taught.
The end date of employment must be on or before today’s date; future end dates, "to present", and/or incomplete forms
will not be accepted.
Employee Information
First Name:
Last Name:
Middle Initial:
Date of Birth: / / (mm/dd/yyyy)
Last 4 Digits of Social Security Number:
Certificate title(s) for which the certificate holder is requesting this form be completed:
Full-Time Experience
If the applicant was employed in a continuous, full-time position for an entire academic year, enter the academic year of
employment (e.g., 2018-2019), position, and grade level(s) taught (see instructions above). One academic year is
considered 180 days between July 1 and June 30. For all other experience, please complete the "Part-Time Experience"
section on the next page.
Academic Year:
Position (Subject/Title): Grade Level(s):
Academic
Year:
Position (Subject/Title): Grade Level(s):
Academic
Year:
Position (Subject/Title): Grade Level(s):
For additional years, please make copies of this page to extend the form.
Attestation of Experience
I verify that the indicated individual gained the paid experience listed above at the public/private school of which I am the Superintendent,
Superintendent’s designee, Director of Human Resources, Chief School Officer of the approved non-public/independent school, or, in the
case of Speech and Language Disabilities or Students with Disabilities experience only, the authorized official listed for the approved
contracting agency.
Name of School or Employer:
Address of School or Employer:
Print Name of Administrator:
Administrative Title:
Signature of Administrator: Today’s Date: / / (mm/dd/yyyy)
Email: Phone Number: ( )
(rev. 4/2020)
Part-Time Experience
If the applicant was employed part-time, enter the total full-time equivalent days worked during each academic year. A
maximum of 180 days in an academic year can be accepted (July 1 – June 30). Hourly employment must be converted to
full-time equivalencies.
Employment Year 1: From: / / (mm/dd/yyyy) to: / / (mm/dd/yyyy)
Position (Subject/Title):
Grade Level(s):
Total number of full-time equivalent days worked:
a. During the academic year, the experience averaged 2.5 days per week in the subject area and was
completed in periods of no less than 90 days.
b. During the academic year, the experience included at least 45 days of part-time, continuous school experience in the
subject area and consisted of at least one class period each day with a consistent group of students during such time
period.
c. Neither a or b.
Employment Year 2: From: / / (mm/dd/yyyy) to: / / (mm/dd/yyyy)
Position (Subject/Title):
Grade Level(s):
Total number of full-time equivalent days worked:
a. During the academic year, the experience averaged 2.5 days per week in the subject area and was
completed in periods of no less than 90 days.
b. During the academic year, the experience included at least 45 days of part-time, continuous school experience in the
subject area and consisted of at least one class period each day with a consistent group of students during such time
period.
c. Neither a or b.
Employment Year 3: From: / / (mm/dd/yyyy) to: / / (mm/dd/yyyy)
Position (Subject/Title):
Grade Level(s):
Total number of full-time equivalent days worked:
a. During the academic year, the experience averaged 2.5 days per week in the subject area and was
completed in periods of no less than 90 days.
b. During the academic year, the experience included at least 45 days of part-time, continuous school experience in the
subject area and consisted of at least one class period each day with a consistent group of students during such time
period.
c. Neither a or b.
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Classroom Teachers and Pupil Personnel Services Professionals (New York State Education Department)

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Completed 9 August 2021

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