June 2019
Clock Hour Approval Application Form
This form is to be submitted with each request for clock hours to the local continuing education committee
according to rules established by the local committee. View the Minnesota Administrative Rules 8710.7200 Clock
Hours; Requirements for Renewal of Professional Licenses (https://www.revisor.mn.gov/rules/?id=8710.7200
Duplicate this form as needed.
File Folder Number:
Licenses Held: Expiration Date:
Applicant Signature: Date:
Request for:
Preapproval of clock hours subject to actual completion
Final approval of clock hours for professional activity completed
Number of Clock
Hours Requested:
This activity addresses:
Positive behavior intervention strategies
Accommodating, Modifying, and Adapting Curricula, Materials, and Strategies to appropriately meet
the needs of individual students and ensure adequate progress toward the state's graduation rule.
Further reading preparation as defined in Minnesota Statute 122A.06, Subd. 4
(https://www.revisor.mn.gov/statutes/?id=122A.06#stat.122A.06.2). This requirement applies to all
professional licenses issued by the Minnesota Professional Educator Licensing and Standards Board,
except school counselors, school psychologists, school nurses, school social workers, audiovisual directors
and coordinators, and recreation personnel.
Key warning signs of early-onset mental illness in children and adolescents, including a minimum of one
hour of suicide prevention
Evidence of instructor growth in English Language Learner Instruction as evident in the summative
evaluation or district approved training that aligns with Interstate Teacher Assessment and Support
Consortium (InTASC) standards for English learners.
Cultural Competency Training evidenced for renewals beginning in 2020 and thereafter.
Local Committee Action
Approved: Number of
Clock Hours:
Not Approved Reason:
Committee Signature: Date: