Fillable f1678 PI-1678 Employment Verification for National Teacher Certification by NBPTS or Wisconsin Master Educator License by WMEAP

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f1678 PI-1678 Employment Verification for National Teacher Certification by NBPTS or Wisconsin Master Educator License by WMEAP

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—Complete remainder of application on Page 2—
Wisconsin Department of Public Instruction
EMPLOYMENT VERIFICATION FOR
NATIONAL TEACHER CERTIFICATION BY NBPTS OR
WISCONSIN MASTER EDUCATOR LICENSE BY WMEAP
PI-1678 (Rev. 09-19)
INSTRUCTIONS TO APPLICANT: Attach to Initial
Reimbursement Grant Applicatio
n or Annual Grant
Application.
INSTRUCTIONS TO EMPLOYER: Complete pages 1
and 2. Return application to applicant.
This form is available at dpi.wi.gov/tepdl/programs/nbpts-reimbursement-grant
or
dpi.wi.gov/tepdl/programs/wmeap-reimbursement-and-grant
To the Applicant: Complete Section I of this form (print or type) and forward it to your district administrator or personnel director for completion.
I. APPLICANT INFORMATION
Applicant Name Last, First, Middle Previous Name
DPI Educator Entity Number
Name of Employing School District / Agency / Private School
II. EMPLOYMENT HISTORY
To the Employer: Complete Sections II, III, and IV of this form and return to the applicant.
This employment verification relates to PI 37 National Teacher Certification or Wisconsin Master Educator License. The following definitions apply:
PI 37.02 (7) “Teacher” means properly licensed persons delivering instruction to pupils; or school psychologists, school counselors, or school social
workers. Teacher does not include a person working under contract as an administrator.
PI 37.02 (2) “Employed as a teacher” means a person working as a teacher for a minimum of 40 percent full-time equivalency for at least 180 days in
a school year.
Total days during the 2019-20 school year this applicant is “employed as a teacher” for your school district / agency/
private school:
Total Days
If applicant is employed at multiple schools in the district, please complete as many columns as necessary to represent all schools.
A. School Employed At B. School Employed At C. School Employed At
Enter all percentages below as a whole number, i.e., 80 not .80 or 80.00
A. “Teacher” position at this school B. “Teacher” position at this school C. “Teacher” position at this school
Teacher
School Counselor
School Social Worker
School Psychologist
% FTE
% FTE
% FTE
% FTE
Teacher
School Counselor
School Social Worker
School Psychologist
% FTE
% FTE
% FTE
% FTE
Teacher
School Counselor
School Social Worker
School Psychologist
% FTE
% FTE
% FTE
% FTE
Is this “teacher” working under contract as an
administrator in any of these positions?
No Yes
Is this “teacher” working under contract as an
administrator in any of these positions?
No Yes
Is this “teacher” working under contract as an
administrator in any of these positions?
No Yes
Page 2 PI-1678
III. EDUCATOR EFFECTIVENESS SYSTEM RATING
School Year Applicant Received National Teacher Certification by NBPTS Initial Reimbursement or Master Educator
License by WMEAP Initial Reimbursement Grant:
School Year
Applicants who received the National Teacher Certification by NBPTS Initial Reimbursement or Master Educator License by WMEAP Initial
Reimbursement grants in the 2014-15 school year and thereafter, are required to provide annual verification of being “effective or highly effective” in
the Educator Effectiveness System as part of the Initial and Annual Grant application process.
Rating of “effective or highly effective” means a score of equal to or greater than 2.5 in both the educator practice outcome summary and the student
outcomes summary or, if the person has not had an initial evaluation, the person is in the process of being evaluated.
Has the applicant had a rating in the applicable Educator Effectiveness system?
Yes, If yes, has the applicant been rated, based on the definition above, effective or highly effective?
In the process of being evaluated.
Not required to be evaluated in the applicable Educator Effectiveness System.
Yes No
IV. VERIFICATION BY EMPLOYER
TO THE BEST OF MY KNOWLEDGE, all information presented on this form is accurate.
Name of School District or Employer
Street
City, State, ZIP Code
District Administrator or Personnel Director’s Name First and Last—Type or print legibly
Signature of District Administrator or Personnel Director Must be original—blue ink, not a copy.
Date Signed Mo./Day/Yr.
Title
Email
Employer Phone Area/No.
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f1678 PI-1678 Employment Verification for National Teacher Certification by NBPTS or Wisconsin Master Educator License by WMEAP

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Completed 26 September 2019

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