Fillable O hiORESA RESA Modification Request Form 2020-2021 (City of Oakland)

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O hiORESA RESA Modification Request Form 2020-2021 (City of Oakland)

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The O hiORESA RESA Modification Request Form 2020-2021 (City of Oakland) form is 2 pages long and contains:

  • 2 signatures
  • 3 check-boxes
  • 20 other fields

Country of origin: US
File type: PDF

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O
hiORESA
O hiORESA
RESA Modification Request Form 2020-2021
Directions:
This form is to be completed by Resident Educators with the help of their program Coordinator.
Resident Educators are required to complete this form if they believe they are unable to complete the Lesson
Reflection and record their lesson as outlined in the RESA Guidebook. Please note, this form
does not exempt
Resident Educators from the RESA,
but if approved
, the Resident Educator will receive a modification of the
Lesson Reflection. The Resident Educator will be contacted to schedule the modification. Incomplete forms
are not accepted.
Submission deadline: October 10, 2020
.
Resident Educator’s Information (Type or Print)
Program Coordinator’s Information (Type or Print)
Name:
Name:
Educator State ID #:
Educator State ID #:
Email Address:
Email Address:
Building Name & IRN:
District Name & IRN:
Phone:
Phone:
Reason for Modification Request (check one):
________ Facility does not permit videotaping of students.
________ Parental Consent cannot be obtained
________ Unique circumstances*
* Please provide a detailed description of your unique circumstances and explain why you believe you
need a modification. Attach additional sheet if needed.
Building Administrator Name, Email and Phone:
Location of observation (full name and address)
Program Coordinator’s Signature Date
Resident Educator’s Signature Date
Please submit the completed form to OhioRESA@education.ohio.gov by attaching this form to the email. If you have
questions, contact Virginia Cardwell at virginia.cardwell@education.ohio.gov or (614) 387-0143.
Rev. 2020
Phone
(Signature verifies the information above is accurate.)
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signature
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signature
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O
hiORESA
For Internal Use Only
Date Received:
Date PC/RE Notified of Approval: ______________________
Date PC/RE Notified of Non-Approval: __________________
Approved by:
Rev. 2020
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O hiORESA RESA Modification Request Form 2020-2021 (City of Oakland)

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Completed 28 October 2020

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