Office of the Superintendent for Public Instruction



Office of the Superintendent for Public Instruction

Professional Education and Certification

Old Capitol Building, FG-11, Olympia WA 98504-3211

360-725-6400

CONTINUING EDUCATION AND VOCATIONAL CLOCK HOURS

PRIOR NOTICE

Approved continuing education providers must submit this form and required information 30 days in advance of any offering (10 days if a previously approved program is to be offered at a different location) to: Professional Education and Certification, Superintendent of Public Instruction, Old Capitol Building, FG-11, Olympia, WA 98504-3211 -OR- Approved provider: Auburn School District, 915 Fourth Street NE, Auburn, WA 98002.

SCHOOL/LOCATION:

Type of Plan (Please circle one): PDM LID Other

|1. SPONSORING PROVIDER NAME* |2. SPONSORING PROVIDER ADDRESS |

| | |

|Auburn School District |James P. Fugate Administration Bldg. |

| |915 Fourth Street Northeast |

| |Auburn, WA 98002 |

|3. TITLE OF OFFERING: |

|4. DAYS OF OFFERING |5. TIME OF OFFERING |6. NUMBER OF CONTINUING |

| | |CLOCK HOURS |

|7. NAME OF INSTRUCTOR(S) |8. WRITTEN OBJECTIVES ATTACHED |

| | |

| |( YES ( NO |

|9. QUALIFICATIONS OF INSTRUCTOR ATTACHED |REQUESTING APPROVAL FOR VOCATIONAL |

| |CLOCK HOURS |

|( YES ( NO |( YES ( NO |

|Does thIS COURSE MEET the requirments for STEM Clock Hours? ( YES ( NO |

| |

|In order to meet this requirement the offering must do ALL of the following and clearly be shown in the offerings Agenda: |

|Have an impact on STEM experiences for students? |

|Provides examples or resources to use with students or with other educators? |

|Provides examples or resources about STEM-related career choices to use with students? |

|12. EVALUATION FORM** |

| |

|( ATTACHED ( PREVIOUSLY SUBMITTED |

| |

|Must include: |

|extent to which written objectives have been met |

|quality of the physical facilities |

|quality of the oral presentation by each instructor |

|quality of the written materials provided by each instructor |

|13. WILL CANDIDATES HAVE THE OPTION OF USING |14. IF YES, NAME COLLEGE OR UNIVERSITY |

|THIS OFFERING FOR COLLEGE OR UNIVERSITY | |

|CREDIT? | |

| | |

|( YES ( NO | |

*If items 1 through 8 are included on the program agenda, that agenda may be submitted or attached

to this form in lieu of written responses to items 1 through 8.

**If a continuing education provider is using the same evaluation form for all activities, submission

of the evaluation form will only be required for the first program.

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