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
School Building Leaders/School Administrator Supervisors
This form must be completed and submitted by one of the following individuals: Superintendent, Superintendent’s designee,
Director of Human Resources, or Chief School Officer of the approved non-public/independent school.
New York State employers with access to TEACH should submit a Superintendent Statement through the TEACH Online System
instead of this form, if
the paid experience to be verified is in one of the traditional administrative titles (e.g., Principal, Assistant
Principal). Experience in all other administrative titles must be verified using this form.
NYCDOE administrative experience must be verified electronically by the NYCDOE Supervisory Staffing Unit. The NYCDOE Supervisory
Staffing Unit does not use this form and can be contacted at: (718) 935-2822 or SupervisorySupport@schools.nyc.gov
.
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 does 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.
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. For part-time or full-time experience that was not for an entire academic year, the number of full-time equivalent days
worked must be included.
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:
Employment Year 1 – A maximum of 180 full-time days in an academic year can be accepted (July 1 – June 30).
Position (Title):
Full-time: Total number of full-time equivalent days worked:
From: / / (mm/dd/yyyy) to: / / (mm/dd/yyyy)
Part-time: Total number of full-time equivalent days worked: Hourly employment must be converted to full-time equivalencies.
From: / / (mm/dd/yyyy) to: / / (mm/dd/yyyy)
For positions other than Principal or Assistant Principal, please answer #1-5 below. For Principal or Assistant Principal positions, skip #1-5.
1. Was the position in the unclassified service (not civil service)? Yes No
2. The number of contractual periods per day that the educator was assigned to administrative duties was .
3.
The number of contractual periods per day that the educator was assigned to teaching duties was .
4.
The number of teachers or other certified professionals supervised by the educator was .
5. Check the type of experience completed (mark only one box): School building level District level
Instructional Support Services (ISS) in professional development, pedagogical support, technical assistance, consultation, and/or program
coordination offered by teachers to other school personnel.
