800 Troy-Schenectady Road, Latham, NY 12110-2455
518-213-6000 800-528-6208 FAX 518-213-6456
elt.nysut.org
TRAINING IN THE NEEDS OF STUDENTS WITH AUTISM
ONLINE REPORTING FORM FOR CERTIFICATION
Instructions:
Please fill out this form and send to ELT at ELT@nysut.org upon successful completion of
your Autism Spectrum Disorder: Adjusting the Educational Image seminar.
NYSUT ELT will electronically report your attendance to the New York State Education
Department Office of Teaching Initiatives and will retain verification of workshop completion for
not less than six years from the date of the workshop.
Please print your name exactly as it currently appears on your TEACH account with the
New York State Education Department:
Last Name:
First Name:
ID (SSN): X X X - X 0 - 0 0 0 0
Date of Birth:
/ /
Last 5 digits are required
MM
DD YY
Address:
City: State: Zip:
Phone: Email:
Seminar completion date:
Instructor:
Format:
