Tennessee



|[pic] |Tennessee Department of Children’s Services |

| |Professional Development Waiver |

|Employee Name:       |Employee ID: |      |Job Title:       |

|Region/YDC/Central Office:       |Supervisor:       |

|Person Making Request:       |Title:       |Date of Request:       |

|Waiver Type |

| General (FMLA, Military Leave) *See form Instructions for | Profession (attorney, psychologist…) | Graduate Assistant |

|definition | | |

| Other (Explain) |

|Details of request (list reasons for request, employee qualifications that make them exempt and any other pertinent information):       |

|Substitution Course Data |

|*If requesting to substitute a course, provide information below. |

|Course Title:       |Substitution Course Title:       |

|Professional Development Source for Substitution Course:       |

|(i.e., CBT, Internal Offering, External Agency, etc.) |

|Date completed:       |Number of Hours:       |

|Course Description:       |

|Certificate of Completion Attached: Yes No |

|(A copy of this certificate must accompany this request) |

|Approvals |

| Approved Denied |Reason for Denial:       |

|Supervisor Print: |Supervisor Signature: |

|      |      |

|RA/RID/Superintendent Print:       |RA/RID/Superintendent Signature:       |Date:       |

|DO NOT WRITE BELOW THIS LINE --- FOR THE TRAINING DIVISION ONLY |

| Approved Denied |Reason for Denial:       |

|Training Designee Print: |Training Designee Signature: |

|      |      |

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