Faculty member – meet with your department chair to complete this form.
Instructor Name: ________________________________________________________________________
Date: ___________________________ Email Address: _______________________________________
Course Name: __________________________________________________________________________
Course No.: ___________________ Section: __________________ Hours: ____________________
Department: _______________________________________ Semester/Year Offered: ______________
Is this the first time this course will be offered via Distance Learning? Yes __________ No _________
First time this instructor is teaching a course via DL at SUNY Orange? Yes __________ No __________
Type of Online Course:
Distance Learning (fully online)
Will this course require proctored testing on Campus? __________
Will this course require proctored testing at an off-campus location? _____________
(Instructor must provide proctoring)
Will this course require field trips or on-campus learning experiences? ____________
If yes, please describe:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Hybrid (Course meets ½ time on campus and ½ time online)
Day/Time that the course will meet on campus? ________________________________________________
(Classes which usually meet three days a week must meet twice weekly on campus)
Web-Enhanced Required (Students required to use online component. Students will be notified of this
in the bulletin so they can make an informed decision).
Web-Enhanced Optional (Web component available but not counted toward grade).
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THIS SECTION TO BE COMPLETED BY DEPARTMENT CHAIR:
Has this instructor completed Angel training? ________
Will this course be taught on load or extra compensation? ______________________
If on load, what effect will it have on day sections? ___________________________
Chair Signature for Approval: _____________________________________________ Date: ____________
(If approval is not given, please return to instructor with reasons for denial).
DEPARTMENT CHAIR, PLEASE FORWARD THIS FORM TO YOUR AVP FOR APPROVAL
AVP Name __________________________________________________________
AVP Signature for Approval _____________________________________________ Date: _____________
With AVP Approval, please cc: Department Chair, Originating Instructor, Registrar, and Coordinator of Instructional Technology
