Rev. July 24, 2020
Application Type - EL
EDUCATIONAL LEADER CERTIFICATION APPLICATION PACKET
Dear Applicant:
With the completion of the Educational Leader Packet you can request certification for Educational Leader Level 1, Educational Leader
Level 2, and Educational Leader Level 3, or the Ancillary Special Education Educational Leader. A letter of eligibility for Educational
Leader certification will be issued to individuals who meet requirements, but who are not yet hired in a leadership position. The appropriate
leadership certificate will be issued upon employment in a leadership capacity per the request of the employing Louisiana Employing
Authority (the employer would submit a letter indicating your employment including a professional conduct form). Louisiana Employing
Authorities have been informed that a letter of eligibility issued by the LA Dept. of Education is sufficient to identify you as being eligible
for employment and the certificate will be issued upon their request. If employed in a leadership role at the time of application, the
employer will verify date-of-hire and role within the application and the certificate will be issued without a letter of eligibility being
necessary.
Eligibility for EDL1 can be obtained by fulfilling ONE of the following routes:
Master's Degree Path -for certified teachers who have earned an advanced degree in the area of Educational Leadership
Alternate Path 1 -for certified teachers who hold a master's degree and have fulfilled an individualized, competency-based
educational leadership plan-of-study from an institution of higher education accredited in accordance with 34 CFR 602
Alternate Path 2 -for certified teachers who hold a master's degree in education and document evidence of 240 clock hours of
educational leadership experiences (refer to the included Alt Pathway 2 pages for instructions on documenting the experiences)
Alternate Path 3 -for certified teachers who hold a baccalaureate degree from an institution of higher education accredited in
accordance with 34 CFR 602 and have successfully completed a Louisiana competency-based educational leader practitioner
(residency) program
All pathways to the Educational Leader 1 license require the successful completion of either the Praxis School Leaders Licensure
Assessment (SLLA) or the Louisiana Leadership Assessment Series (LLAS).
EDL1 eligibility does not expire. The EDL1 certificate is valid for three years initially, after being issued at the request of the LA
employer, and may be extended thereafter for a period of one year at the request of the LA employer. EDL 1 certificates are limited to
two such extensions in the event the leader cannot advance to the EDL2.
Eligibility for EDL2 requires all of the following:
Valid EDL1 certificate, a Louisiana teaching certificate with provisional principal certification, or comparable level out-of-state
educational leader certificate;
Three years of teaching experience in the area(s) of certification;
Three years of educational leadership experience at the level of assistant principal or above; and
Met the standards of effectiveness as an educational leader for three years (verifiable via Compass and/or where out-of-state
experience has been verified as successful by the employing school system or out-of-state credentialing agency using the
Out-of-State Experience Verification Attestation form)
EDL2 eligibility does not expire. The EDL2 certificate is valid for five years and is renewable by successfully meeting the standards of
effectiveness for at least three years during the five-year initial or renewal period of the EDL2. Effectiveness is verified via Compass
evaluations entered into the Compass Information System, if serving in school-level role; or with local evaluations, as documented on
the Educational Leader Local Evaluation Attestation form (included in this application packet) when serving as a district-level leader, not
evaluated via Compass.
Educational Leader Level 1 (EDL 1)
permits service as a school or district level leader
Educational Leader Level 2 (EDL 2) permits service as a school or district level leader for educators with
successful leadership experience (has met the standards of effectiveness verifiable via Compass or out-of-state
employer).
Rev. July 24, 2020
Application Type - EL
Eligibility for EDL3 requires all of the following:
Valid EDL2 certificate or one of the Louisiana administrative/supervisory certification endorsements preceding the current
educational leadership certification structure;
Five years of teaching experience in the area(s) of certification;
Five years of successful educational administrative/management experience at the level of assistant principal or above
(limiting the assistant principal experience to two years in that position); and
Passing the Praxis School Superintendent Assessment (SSA) exam
EDL3 eligibility does not expire. The EDL3 certificate is valid for five years and is renewable by successfully meeting the standards of
effectiveness for at least three years during the five-year initial or renewal period of the EDL3. Effectiveness is verified via Compass
evaluations entered into the Compass Information System or with local evaluations, as documented on the Educational Leader Local
Evaluation Attestation form included within this application packet.
Eligibility for AN EDL in Sped requires all of the following:
Hold one of the following valid Louisiana ancillary certificates:
o assessment teacher;
o educational consultant;
o educational diagnostician;
o certified school psychologist (Level B or Level A);
o qualified speech pathologist;
o speech therapist;
o speech-language pathologist;
o speech and hearing therapist;
o qualified school social worker; or
o qualified licensed audiologist;
Three years of experience working with students in the area(s) of certification;
Graduate degree from
an institution of higher education accredited in accordance with 34 CFR 602;
Documented 240 clock hours of educational leadership experiences (refer to the following pages for instructions on
documenting the experiences); and
Successful completion of either the Praxis School Leaders Licensure Assessment (SLLA) or the
Louisiana Leadership
Assessment Series (LLAS).
AN EDL in Sped eligibility does not expire. The AN EDL in Sped certificate is valid for five years and is renewable by successfully
meeting the standards of effectiveness for at least three years during the five-year initial or renewal period of the certificate.
Effectiveness is verified via Compass evaluations entered into the Compass Information System or with local evaluations as
documented on the Educational Leader Local Evaluation Attestation form included within this application packet.
Louisiana also offers the Out-of-State Principal (OSP) and Out-of-State-Superintendent (OSS) certificates for those leaders who haven’t
completed Louisiana’s licensing exams but who have leadership experience and certification in another state.
Out-of-State Principal Out-of-State Superintendent
Experienced, certified educators who do not qualify for EDL certification, but may qualify for OSP or OSS would apply for certification
eligibility using the Out of State Administrative Application. Do NOT submit the EDL packet for OSP or OSS application.
Educational Leader Level 3 (EDL 3) permits service as a school superintendent or assistant superintendent
Educational Leader in Special Education Ancillary (AN EDL in Sped) permits service as a
school or district supervisor, director, or coordinator of special education, ONLY.
Out of State Certified Principal & Superintendent
permits service as a principal or superintendent
Rev. July 24, 2020
EDL Application Process
Please submit a complete application packet through the online educator certification portal.
Use the appropriate checklist below to ensure a complete application packet is submitted to avoid additional
certification fees and delayed processing.
Initial EDL1 via Master’s Degree Path:
Application for Educational Leader Certificate form with all information provided
Professional Conduct form with all questions answered, signed, and dated by the applicant
Exam Documentation copy of SLLA or LLAS score report
Transcript with Educational Leadership Graduate Degree Awarded/Conferred - official transcripts should be sent
(mailed or emailed) directly to you and will be considered official when scanned and/or uploaded to the online
certification portal. Check that the degree is indicated as awarded/conferred with date.
Copy of teaching certificate (required only if not certified as a teacher in Louisiana)
Out-of-State Experience Verification Attestation form (if applicable)
Certification Processing Fee (copy of confirmation email or screenshot of payment of $50.00 payable to the LDOE
online at https://www.billerpayments.com/app/simplepayui/?bsn=sladoeteachcert
)
Initial EDL1 via Alternate Pathway 1
(Individualized Program):
Application for Educational Leader Certificate form with all information provided
Professional Conduct form with all questions answered, signed, and dated by the applicant
Exam Documentation copy of SLLA or LLAS score report
Transcript with Graduate Degree Awarded/Conferred - official transcripts should be sent (mailed or emailed) directly
to you and will be considered official when scanned and/or uploaded to the online certification portal. Check that
the degree is indicated as awarded/conferred with date.
Completion Letter from Institution indicating successful completion of individualized program
Copy of teaching certificate (required only if not certified as a teacher in Louisiana)
Out-of-State Experience Verification Attestation form (if applicable)
Certification Processing Fee (copy of confirmation email or screenshot of payment of $50.00 payable to the LDOE
online at https://www.billerpayments.com/app/simplepayui/?bsn=sladoeteachcert
)
Initial EDL1 via Alternate Pathway 2
(Documented 240 Clock Hours):
Application for Educational Leader Certificate form with all information provided
Professional Conduct form with all questions answered, signed, and dated by the applicant
Exam Documentation copy of SLLA or LLAS score report
Transcript with Graduate Degree in Education Awarded/Conferred - official transcripts should be sent (mailed or
emailed) directly to you and will be considered official when scanned and/or uploaded to the online certification
portal. Check that the degree is indicated as awarded/conferred with date.
Educational Leadership Portfolio of 240 Clock Hourslimited to 100 pages & organized/ordered as follows:
Leadership Experience Calculation Chart listing documented 240 clock hours
Summary Sheets for each experience listed on the chart placing the associated artifact directly behind each
Copy of teaching certificate (required only if not certified as a teacher in Louisiana)
Out-of-State Experience Verification Attestation form (if applicable)
Certification Processing Fee (copy of confirmation email or screenshot of payment of $50.00 payable to the LDOE
online at https://www.billerpayments.com/app/simplepayui/?bsn=sladoeteachcert
)
Initial EDL1 via Alternate Pathway 3
(Practitioner/Residency Leader Program):
Application for Educational Leader Certificate form with all information provided
Professional Conduct form with all questions answered, signed, and dated by the applicant
Exam Documentationcopy of SLLA or LLAS score report
Educational Leader Practitioner/Residency Completion Verification form signed by program provider
Copy of teaching certificate (required only if not certified as a teacher in Louisiana)
Out-of-State Experience Verification Attestation form (if applicable)
Certification Processing Fee (copy of confirmation email or screenshot of payment of $50.00 payable to the LDOE
online at https://www.billerpayments.com/app/simplepayui/?bsn=sladoeteachcert
)
Rev. July 24, 2020
Extending EDL1 (Submitted by LA Employing School System ONLY)
Application for Educational Leader Certificate form with all information provided
Professional Conduct form with all questions answered, signed, and dated by the applicant
Certification Processing Fee (copy of confirmation email or screenshot of payment of $25.00 payable to the LDOE
online at https://www.billerpayments.com/app/simplepayui/?bsn=sladoeteachcert
)
Advancing EDL1 to EDL2OR- Renewal of EDL2 or EDL3 (Submitted by LA Employing School System ONLY)
Application for Educational Leader Certificate form with all information provided
Professional Conduct form with all questions answered, signed, and dated by the applicant
Certification Processing Fee (copy of confirmation email or screenshot of payment of $25.00 payable to the LDOE
online at https://www.billerpayments.com/app/simplepayui/?bsn=sladoeteachcert
)
Ed Leader Local Evaluation Attestation form if serving as a district-level leader not evaluated via Compass
Initial EDL2 (Did not hold EDL1)
Application for Educational Leader Certificate form with all information provided
Professional Conduct form with all questions answered, signed, and dated by the applicant
All Transcripts not already provided to the LDOE with past certification requests - official transcripts should be sent
(mailed or emailed) directly to you and will be considered official when scanned and/or uploaded to the online
certification portal. Check that the degree is indicated as awarded/conferred with date.
Copy of teacher and leadership certifications (required only if not certified as a teacher in Louisiana)
Out-of-State Experience Verification Attestation form (if applicable)
Certification Processing Fee (copy of confirmation email or screenshot of payment of $50.00 payable to the LDOE
online at https://www.billerpayments.com/app/simplepayui/?bsn=sladoeteachcert
)
Initial EDL3
Application for Educational Leader Certificate form with all information provided
Professional Conduct form with all questions answered, signed, and dated by the applicant
Exam Documentation copy of SSA score report
Out-of-State Experience Verification Attestation form (if applicable)
Certification Processing Fee (copy of confirmation email or screenshot of payment of $25.00 payable to the LDOE
online at https://www.billerpayments.com/app/simplepayui/?bsn=sladoeteachcert
)
Contact Information: All questions regarding certification requirements or the certification process, can be answered
by contacting the Louisiana Department of Education’s online educator certification portal
.
All applications will be evaluated in the order in which they are received. You can check the status of your certification
application online HERE
.
2
EDUCATIONAL LEADER APPLICATION
Are you currently employed in an educational leadership role? YES NO
If YES, what is your title/role and what date
were you hired in this leadership role? Title/Role: ___________________________
Date Hired: ____________
If NO, a letter of eligibility will be issued which can be used to obtain employment.
Louisiana School
System
(if out-of-state, use Out-of-
State Exp Verification
Attestation form)
NAME OF SCHOOL
Type of School
School
Year(s) Served
(Ex. 08-09, 09-10 etc.)
Position
(principal, educational
leader title, etc.) Public Private
-
-
-
-
I agree that my electronic signature as entered below is the legal equivalent of my manual signature on this application.
Signature of Applicant: ______________________________ Date: _________________
Indicate certification transaction requested (if transcripts are submitted degrees will be added to the certification record):
Educational Leader Level 1 via Masters Path
Educational Leader Level 1 via Alternate Path 1 (Individualized Program)
Educational Leader Level 1 via Alternate Path 2 (Documented 240 Clock Hours)
Educational Leader Level 1 via Alternate Path 3 (Practitioner/Residency Leader Program)
Educational Leader Level 2
Educational Leader Level 3
Educational Leader in Sped (Ancillary)
Renewal/Extension of Educational Leader Level 1, 2, 3, or Sped Ancillary
Social Security Number ______ - ______ - ______ Date of Birth _________________________
Name of Applicant: _____________________________________________________________________
(First) (Middle) (Last)
Check here for name change (include a copy of the updated Social Security Card -AND- updated driver's license/state ID)
Address: _____________________________________________________________________________
(Street) (City) (State) (Zip Code)
Phone: Home: (____)__________ Work: (____)___________ Email Address:_______________________
Online Payment Confirmation # _________________
To be completed by Superintendent or Human Resource Director:
With my signature below I am verifying that the experience as listed above was successful, complete and correct according to the
official records on file in the Louisiana approved public or nonpublic school system providing this verification. I agree that my
electronic signature as entered below is the legal equivalent of my manual signature on this application.
_____________________________________________ _____________________
Signature of Louisiana Employing Authority Date
Rev. July 24, 2020
PLEASE TYPE OR PRINT IN INK
PROFESSIONAL CONDUCT FORM
(All questions must be answered)
NAME OF APPLICANT:
(Include First, Middle, Maiden, and Married)
Social Security Number:
______ - ______ -______
ADDRESS: DATE OF BIRTH:
Each Question must be answered: Please Check
YES NO
1. Have you ever had any professional license/certificate denied, suspended, revoked,
or voluntarily surrendered?
If YES, in which state?____________________________
2. Are you currently being reviewed or investigated for purposes of such action as
stated in #1 or is such action pending?
If YES, in which state?_____________________________
3. Have you ever been convicted of any felony offense, been found guilty or entered a
plea of nolo contendere (no contest), even if adjudication was withheld?
If yes, please provide the following information:
Date of Conviction: ____________________
State of Conviction: _____ Court Jurisdiction of Conviction: __________________
4. Have you ever been convicted of a misdemeanor offense that involves any of the
following:
a. Sexual or physical abuse of a minor child or other illegal conduct with a minor
child.
b. The possession, use, or distribution of any illegal drug as defined by Louisiana
or federal law.
5. Have you ever been granted a pardon or expungement* for any offense as stated in
#3 or #4?
NOTICE---EXPUNGEMENTS, FIRST OFFENDER PARDONS, PRE-TRIAL DIVERSIONS: Criminal
Background Checks (CBCs) conducted for purposes of employment will be conducted in accordance with
La. R.S. 17:15 and La. R.S. 15:587.1. Pursuant to Louisiana law R.S. 15:587.1., background checks shall
disclose ALL ARRESTS, COURT ACTION and CONVICTIONS, (Including but not limited to expungements, first
offender pardons and pre-trial diversion), and a copy of the report shall be provided to the Louisiana
Department of Education (LDE), in addition to the potential employer or LA Education Agency (LEAs)s.
*Per BESE policy set forth in Bulletin 746, Louisiana Standards for State Certification of School Personnel, Section 903.C,
failuretodiscloseactionssuchasfirstoffenderpardons,pretrialdiversion,expungements,etc.isgroundsforcertification
denialand/orrevocation.”
If you answered “YES” to any questions, #1 through #5, you must provide court certified copies of all documents
and proceedings, civil records of Federal, State and/or District School Board actions, or other relevant documents
that provide full disclosure of the nature and circumstances of EACH separate incident in your application packet.
I affirm and declare that all information given by me in the responses to items #1 through #5 above is true,
correct, and complete to the best of my knowledge. I understand that any misrepresentation of facts, by
omission or addition, may result in criminal prosecution and/or the denial or revocation of my teacher
certificate.
I agree that my electronic signature as entered below is the legal equivalent of my manual
signature on this document.
SIGNATURE OF APPLICANT: DATE:
Rev. 7/29/19
LOUISIANA DEPARTMENT OF EDUCATION
EDUCATIONAL LEADER LOCAL EVALUATION ATTESTATION FORM
PLEASE TYPE OR PRINT IN INK
Louisiana Certificate Type/Number: __________ Social Security Number: ________ - _____ - ________
Name: ____________________________________________________ Date of Birth: ____/____/____
(First) (Middle) (Birth) (Last)
Address: __________________________________________ Phone #: (_____) _________________
(Street) (City/State) (Zip Code)
PLEASE COMPLETE FOR EACH SCHOOL YEAR LOCAL EVALUATIONS ARE USED.
Parish/District
School year (YYYY-YYYY)
Leader position or title
Local rating scale
Please include details of your local
evaluation rating scale.
Evaluation Score
(numeric)
Evaluation Rating
(effective/ineffective)
Evaluator Name & title
Evaluator Signature
Parish/District
School year (YYYY-YYYY)
Leader position or
title
Effectiveness rating scale
Evaluation Score
(numeric)
Evaluation Rating
Evaluator Name & title
Evaluator Signature
Parish/District
School year (YYYY-YYYY)
Leader position or
title
Effectiveness rating scale
Evaluation Score
(numeric)
Evaluation Rating
Evaluator Name & title
Evaluator Signature
For all parties signing this document:
I attest to the validity of the above effectiveness ratings. I agree that my electronic signature as entered on this form is the
legal equivalent of my manual signature on this application.
SIGNATURE OF EMPLOYING AUTHORITY: DATE:
TITLE & DISTRICT OF EMPLOYING AUTHORITY: EMAIL:
Rev. 7/24/2020
INSTRUCTIONS:
PORTFOLIO DOCUMENTING EDUCATIONAL LEADERSHIP ALTERNATE PATH 2 (240 CLOCK HOURS)
When documenting the 240 clock hours of school or district level educational leadership experiences, the
experiences must cover multiple levels of observation, participation and leadership that directly coincide and
align with the six leadership “Performance Expectations (PE), as listed in
Bulletin 125-Standards for Educational
Leaders in Louisiana found here. A list/chart of suggested experiences is included in this packet for guidance.
Please follow the steps outlined below in constructing your leadership portfolio for consideration by the Louisiana
Department of Education.
1. List each of your leadership experiences on
t
he Leadership Experience Calculation
Chart
(Excluding documented mentor
teacher/content leader experience, no more than 5
0
hour
s will be accepted per leadership experience.)
2. D
ocument EACH listed experience on a
separateSummary Sheet indicating the
corresponding Leadership Exp. #, the
Leadership Performance Expectation from
Bulletin 125, and other requested information
resulting in a brief description of the specific
experience
.
3. Pr
ovide artifacts that speak directly to eac
h
ex
perience activity. The artifacts can be i
n
t
he form of agendas, sign-in sheets,
verification letters, brochures, multimedi
a
pr
esentations, etc. Place the artifacts after
the corresponding “Summary Sheet”.
4. Compile the portfolio, ordering it this way:
“Leadership Experience Calculation
Chart” first,
then the Summary Sheet” for
experience #1,
followed by the corresponding
artifacts for experience #1
,
t
hen the “Summary Sheet” for
experience #2,
followed by the corresponding
artifacts for experience #2
,
a
nd continuing until all listed
experiences are documented with a
“Summary Sheet” followed by
artifacts.
The Portfolio is to be submitted as a single
PDF, not to exceed 100 pages. Only
portfolios submitted following these
guidelines will be considered for certification
or certification eligibility.
Rev. 7/24/2020
***ONLY COMPLETE FOR ALTERNATE PATHWAY 2 APPLICATION/PORTFOLIO***
* If more space is needed, please continue on another page, continuing to number experiences starting with “12” ensuring
a total minimum of 240 clock hours.
** Excluding documented mentor teacher/content leader experience, no more than 50 hours will be accepted per leadership
experience.
I agree that my electronic signature as entered below is the legal equivalent of my manual signature on this application/verification.
Original Signature of Current Employing Authority Title and Name of Employing Authority
Original Signature of Applicant Date
Louisiana Certificate Type/Number: ____________ Social Security Number: ______ - ______ - ______
Name: ___________________________________________________ Date of Birth: _____/_____/_____
(First) (Middle) (Last)
Address: _______________________________________________ Phone #: (_______) ____________
(Street) (City/State) (Zip Code)
Leader-
ship
Experi-
ence
#
Performance
Expectation
# Aligned
with Bulletin
125
# of
Hours**
Site of Experience
(include School, School District, City & State)
Name of Supervisor
(Typed/Printed)
Signature of Supervisor
1
2
3
4
5
6
7
8
9
10
11*
TOTAL HOURS=
LEADERSHIP EXPERIENCE CALCULATION CHART
FOR EDUCATIONAL LEADER ALT PATH 2 (240 CLOCK HOURS)
(I agree that my electronic
signature as entered below
is the legal equivalent of my
manual signature.)
-Select PE-
-Select PE-
-Select PE-
-Select PE-
-Select PE-
-Select PE-
-Select PE-
-Select PE-
-Select PE-
-Select PE-
-Select PE-
Rev. 7/24/2020
SUMMARY SHEET
BRIEF DESCRIPTION OF EDUCATIONAL LEADERSHIP EXPERIENCE ALTERNATE PATH 2
PLEASE TYPE:
This form must be completed for EACH leadership experience listed on the Leadership Experience Calculation
Chart.
Le
adership Experience # as listed on “Leadership Experience Calculation Chart______
Aligns with Bulletin 125 Performance Expectation #______
Number of Hours (Not to exceed 50 per experience): _________________________________
Loc
ation/Site of Experience: _________________________________________
Briefly Describe the Leadership Experience (PLEASE TYPE YOUR EXPLANATION.)
Description will vary depending on the particular activity/experience. The description should include such things as goals of the activity, outcomes of
the activity, participants involved, lessons learned, and other pertinent information.
Goals of Activity:
Le
adership Actions:
P
articipants Involved:
O
utcomes of the Activity:
L
essons Learned:
For each leadership experience, you MUST complete this description page and attach
artifacts and letters of reference that speak to the specific experience.
-Select-
SAMPLE EDUCATIONAL LEADERSHIP EXPERIENCES CONSIDERED FOR
ALTERNATE PATHWAY 2 (240 Clock Hours)
When documenting the 240 clock hours required for obtaining Educational Leadership via alternate pathway 2, the
activities listed below are examples that could be considered. Leadership experiences are required to align with
leadership standards outlined in Bulletin 125
and documented with the leadership portfolio containing artifacts that
support each experience in the form of agendas, sign-in sheets, pictures, copies of presentations, etc. The
documented experiences should include a variety of activities as the portfolio is essentially substituting for a
master’s degree in educational leadership.
Description of Activity
Led an instructional committee that is part of a structured audit or re-examination with the potential re-crafting
of a school’s vision or mission, perhaps in preparation for renewal of accreditation by a regional accreditation
agency (e.g. SACS) or review by the state department of education.
Led a district principals’ meeting and/or a state leadership conference and made a presentation on effective
change practices.
Led the development, scheduling, and implementation of a special activity at the school. (e.g. open house,
student orientation, teacher orientation, literacy initiative, new instructional strategy, school wide fundraising,
career night, etc.).
Led the school leadership team in conducting and analyzing purchases to determine alignment with student
needs.
Led the school’s preparation for a technical assistance visit by a comprehensive school reform group such as
High Schools that Work, Making Middle Grades Work, Teacher Advancement Program. Worked with the
school coordinator to assemble the needed documentation and develop the schedule.
Led a faculty study team in analyzing root causes of poor achievement in core areas such as literacy and
numeracy; formulated and implemented a set of actions and assessed the results.
Led a faculty study team in examining the effectiveness of lower level courses in advancing student
achievement based on results; developed and implemented a plan of action for teaching these students at
higher standards.
Led an articulation project with a feeder school in which the expectations to which the students were held in
lower grades are shared with upper grade teachers, so that teachers can hold students to more rigorous
expectations as they advance from grade to grade.
Observed classrooms for evidence that faculty members have both high expectations for all students and
provide consistent academic support to those who need it so they can be successful at an advanced level.
Cite specific examples observed throughout the school.
Observed classroom lessons with the principal and used the district’s observational documents and processes
to participate in providing feedback to teachers about the extent to which their instruction is standards-based
and engaging to students.
Led a professional development session on a new research-validated instructional strategy aligned with the
school improvement plan. Follow up by coaching and providing feedback to a small group of teachers as they
embed the new strategy into their instructional program.
Led a series of interviews with students focusing on their perceptions of the instructional
strategies used by their teachers. Summarize conclusions for the principal.
Selected or evaluated staff development professionals to learn effective staff development strategies to train
teachers.
Participated in designing a survey for teachers to identify the types of direct assistance teachers desire from
supervisors and from fellow teachers to support student learning, distributed the survey, collected and
analyzed data.
Participated in the development and/or delivery of a professional development workshop focused on the
implementation of research-based teaching strategies to meet the learning needs of students in your school.
Led a series of interviews with teachers focusing on their perceptions of a proposed program of innovation in
the school. Summarize conclusions for the principal.
Planned and/or implemented a student mentoring program to provide caring adult role models. This includes
activities such as the training of adult role models, the development and revision of program resources, and
the monitoring of mentoring sessions with feedback to adult role models as needed.
Planned, administered, analyzed and shared the results of a student satisfaction survey with appropriate
groups.
Planned and implemented a process for teachers to share information gained at professional development
meetings with appropriate members of the school staff. (e.g. professional development sessions, team
meeting, web-based sharing system).
Participated in the development of the master schedule and/or the scheduling of students.
Prepared and/or delivered an explanation of the master schedule to the administration and faculty.
Developed a schedule that provides teams of teachers with common planning time together to review student
data and adjust instructional delivery to meet student needs.
Developed and implemented a schedule that provides time to provide literacy and numeracy interventions
(RTI) to identified students.
Led the development (department level; grade level or whole school) of a grant application.
Served as project administer or manager over a school resource (i.e. grant budget, inventory, shared
computer lab, etc.)
Conducted coaching activities with teachers such as classroom observations with follow-up to debrief, model
lessons to demonstrate effective practices, and/or lesson plan review and feedback to improve instructional
planning.
Served as a district coordinator, school curriculum coordinator, content leader, master teacher, etc.
Served as a mentor teacher for new teachers or a supervising teacher for student teachers Limited to 100
clock hours.
Served successfully as a school assistant principal or principal in an approved school system.
LOUISIANA
Department of Education
Educational Leader Practitioner/Residency Program
Completion Verification Form
(Private Providers Only)
Applicant’sName:______________________________________________________________________
(First)(Middle)(Last)
Candidatecompletedanadministrativeinternatthefollowinglocations:
Schools:______________________________________________District:_________________________
Review of Practitioner Leader’s Performance ( Mid-Year and End of Program)
_____PractitionerleadersuccessfullydemonstratesskillsandknowledgealignedtoLouisiana’seducational
leadershipstandards.
_____Areasofweaknessweredetectedatmidyearreview.Areasofremediationandadditionalstudywere
identifiedforthispractitioner.Aplanofstudywasprescribed.Acopyoftheprescriptionplanisattached.
Educational Leader Level 1 License Status
_____Practitionerleaderhascompletedtheinitialsummerinstit utetrainingandafollowupsummertrainingthat
builtskillsintheareasofinstructional,organizational,andpersonalleadershipbasedoncurriculumalignedto
StandardsforEducationalLeadersinLouisiana.
_____Practitionerleaderhascompletedresidencyexperiencesinatleasttwodifferentschoolsthatcoveredafull
range
ofactivitiesandresponsibilitiesassociatedwithallphasesofschooladministration.
_____Practitionerleaderhascompletedweeklysessionsandaminimumoffourseminarsduringtheschoolyear
thataddressedimmediateneeds.
_____Practitionerleadercompletedaportfoliodemonstratingskillsneededtocollaboratewithteachersanduse
datatoincreasestudenta
chievement;successfullyobserve,evaluate,andprovidefeedbacktoteachersto
improvestudentachievement;andleadtheschooloraportionoftheschoolthroughachangeprocessthat
helpstobuild apositives choolcomm unity.
_____PractitionerleadercompletedanEducationalLeadershipDevelopmentPlan(anindividualizedlearningplan
thatoutlinesareasofdeve
lopmentineachoftheStandardsforEducationalLeadersinLouisiana).
_____Practitionerleaderreceivedsupport,oneononesupervisionandplacedatanappropriatesitewithastrong
principal.
_____Practitionerleaderhascompletedaminimumof125daysservingasanadministrativeinternandapassing
scoreontheSchoolLeadersLicensureAssessment.
Private Providers recommending candidates for Educational Leader Level 1 certification must verify that all program requirements have
beenmet.Thesupportteam(e.g.,residencysupervisor,schoolbasedprincipalmentor,etc.)mus tmeettoreviewtheperformanceofthe
practitionertodetermineifhe/shehasdemonstratededucationalleadershipproficiencyandreadinessforlicensure.
IcertifythattheabovenamedapplicanthascompletedallrequirementsofthisapprovedEducationalLeaderPractitionerProgramas
specifiedbytheLouisianaDepartmentofEducation,andIherebyrecommendthisindividualforcertification.
_______________________________
________________________________________
SignatureofPrivateProvi
der
Date
________________________________________
Name of BESE-approved LA Program Provider
Rev. 7/14/2020
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