NEW YORK STATE EDUCATION DEPARTMENT
NEW YORK STATE EDUCATION DEPARTMENT
INSTRUCTOR QUALIFICATIONS FORM
SCHOOL VIOLENCE PREVENTION AND INTERVENTION
INSTRUCTIONS: A completed form is required for each proposed instructor with information specific to his/her training and/or experience that is relevant to teaching a course or providing training in school violence prevention and intervention. After initial approval, continue to update instructor
information as new instructors are added.
Instructor's Name:
Current employment title:
Name, address, and phone of current employer:
EDUCATIONAL PREPARATION:
Institution Degree Received
Name City/State
If Applicable, list any NEW YORK STATE LICENSE/CERTIFICATE:
Professional Area License/Certificate Number
Please provide a brief description of any professional experience in school violence prevention and intervention training. Please include courses/trainings attended or taught in the area of violence prevention and intervention.
Attach Additional Sheets if Necessary
Attach a course outline or syllabus Revised 11/29/11
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