The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of Teaching Initiatives
Verification of Paid Experience Form for
Special Education Teachers Who Teach a Special Class in Grades 7-12:
Statements of Continued Eligibility (SOCE) and Limited Extensions
This form must be completed by one of the following: Superintendent, Superintendent’s designee, Director of Human
Resources, Chief School Officer of the approved non-public/independent school, or the authorized official listed for the
approved contracting agency.
Instructions for Certificate Holder: Please complete the Employee Information section and then submit the form to your
employer who will complete the additional sections. A separate form must be completed by each employer. The
employer must submit the completed form via email. The Office of Teaching Initiatives will not accept the form if it is
sent by the Certificate Holder. It is suggested that you request a copy of the form for your records.
Instructions for Employer: The form must be submitted to the Office of Teaching Initiatives by the employer via email to
. It is suggested that you provide the certificate holder with a copy of this completed form for
their records. A completed HOUSSE rubric that covers the same years as this form should be submitted with this form by
the employer for each subject area in which the SOCE is sought.
PLEASE NOTE: For the SOCE and limited extension, the special education teacher must have taught the subject area in
which the SOCE is sought in a special class (self-contained class) with students in grades 7-12.
Date of Birth: / / (mm/dd/yyyy)
Last 4 Digits of Social Security Number:
Certificate title for which you are requesting this form be completed:
Employment Year 1:
Grade level(s) taught:
Was the teacher employed in a continuous, full-time position as a special education teacher for the entire school year?
Check each subject area below where the special education teacher taught the subject area in a special class with
students in grades 7-12 for at least one teaching assignment during the school year (e.g., one period for an entire
semester or year).
Biology English Language Arts Social Studies
Chemistry General Science Physics
Earth Science Mathematics Language Other Than English –
Specify Language: ____________
Do you presently employ this teacher in a public school or other school for which teacher certification is required to teach
a special class? Yes No