LEA CODE: - North Carolina



North Carolina Department of Public Instruction

Application for Ed-Flex Waiver of Federal Requirements

A. General Information

|Contact Person: | | |Title: | |

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|E-mail Address: | | |Phone: | |

B. Type of Waiver Requested

1. District-wide waiver: Waiver is requested on behalf of all Title I schools in the LEA.

OR

School specific waiver: Waiver is requested on behalf of the Title I school(s) listed below (use separate sheet, if necessary).

|School Code |School Name(s) |

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2. Check the appropriate box to indicate the program(s) affected by the waiver requested in this application:

☐Title I, Part A of the No Child Left Behind Act (other than sections 1111 and 1116)

(Improving the Academic Achievement of Disadvantaged Children)

☐Title I, Part B, Subpart 3 of the No Child Left Behind Act (Even Start Family Literacy

Program) (Note: LEAs may not waive requirements of the Reading First or Early Reading

First Programs subparts 1 and 2 of Part B of Title I)

☐ Title I, Part C of the No Child Left Behind Act (Education of Migratory Children)

☐ Title I, Part D of the No Child Left Behind Act (Prevention and Intervention Programs for

Children and Youth Who Are Neglected, Delinquent, or At-Risk)

☐ Title I, Part F of the No Child Left Behind Act (Comprehensive School Reform)

☐Title II, Part A, Subparts 2 & 3 of the No Child Left Behind Act (Teacher and Principal

Training and Recruiting Fund)

☐Title II, Part D, Subpart 1 of the No Child Left Behind Act (Enhancing Education through

Technology)

☐Title III, Part B, Subpart 4 of the No Child Left Behind Act (Emergency Immigrant

Education, if this program is funded)

☐Title IV, Part A, Subpart 1 of the No Child Left Behind Act (Safe and Drug-Free Schools and

Communities)

☐Title V, Part A of the ESEA (Innovative Programs)

☐Carl D. Perkins Vocational and Technical Education Act

C. Public Comment

Check any of the following methods for public notice of the waiver requests and opportunity for comments: (Check all that apply.)

 ☐Newspaper

 ☐LEA/School Newsletter

 ☐School Board Meeting

 ☐Press Release

 ☐LEA/School Website

 ☐Other (Specify)_______________________________

Include copies of newspaper notices or other print materials notifying the public of the local education agency’s intent to request a waiver. The public notice must specify the nature of the waiver being requested. If any comments or suggestions were received, submit these comments and suggestions with the waiver request to explain how these comments and suggestions were considered as a part of the waiver process. If the comments or suggestions were not considered, explain why they were not considered.

D. Description of Waiver

1. Describe the specific federal provision to be waived and cite the specific statutory reference:

2. The proposed beginning date for the waiver is __________________________

3. The duration for which the waiver is requested will be: (Check ONLY one.)

 ☐1 year ☐2 years  ☐3 years

4. Purposes, Goals, Activities, and Results

A. Complete a narrative that describes the requested waiver that includes:

1. The specific needs to be addressed through the waiver and the reasons why these needs cannot be met without the waiver;

2. The links between the waiver request and the School Improvement Plan;

3. The links between the waiver request and any possible waivers of state statutes and the regulations that are already in place or that are to be submitted;

4. The specific changes to be made if the waiver is approved (instructional delivery, curriculum offerings, professional development, parental involvement, support services, school governance, school climate, etc.);

5. The possible negative impact on schools not included in the waiver if the waiver is approved (e.g., the impact on the schools in the LEA if a school no longer eligible under Title I was to retain eligibility and funding resulting in other Title I schools receiving less funding than if the waiver was not approved); and

6. The steps that will be taken to ensure that the needs of the intended beneficiaries of the program to be waived continue to be met.

B. Complete the Purposes, Goals, Activities, and Results Table (Table #1 attached) showing how the waiver will improve student achievement in schools affected by the waiver. Submit any data supporting the need for the waiver.

____________________ ____________________ ____________

Ed-Flex Contact’s Name Ed-Flex Contact’s Signature Date Signed

____________________ ____________________ ____________

Superintendent’s Name Superintendent’s Signature Date Signed

Notifications for Requested Waiver(s): Notification will be mailed and emailed within thirty (30) days of the receipt of the application to the local education agency or public charter school requesting waivers.

Submit one completed application for each waiver requested to:

Kenneth Kitch, Ph.D. Telephone: 919-807-3830

North Carolina Department of Public Instruction Facsimile: 919-807-3968

6351 Mail Service Center E-mail: kenneth.kitch@dpi.

Raleigh, NC 27699-6351

North Carolina Department of Public Instruction

Application for Ed-Flex Waiver of Certain Federal Requirements

School Year ______

Table #1 – Purpose, Goals, and Results

LEA CODE: ___________

LEA NAME: _______________________________________

Purpose of the waiver: _________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________

|Measurable Goals (goals must relate to purpose |Activities to be Implemented to Address Each |Evaluation Methods/Expected Results |How Waiver Will Assist the LEA or School(s) in |

|of the waiver stated above) |Measurable Goal | |Reaching the Measurable Goals Listed |

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Agency Use ONLY

Final Waiver Decision: ______ Approved ______ Denied

Date Notification Sent: _____________________________

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