PI-PDP-3 Goal Approval
|[pic] |Wisconsin Department of Public Instruction |INSTRUCTIONS TO EDUCATOR: Complete Part I and submit to your PDP Team members|
| |PDP GOAL APPROVAL FORM |for signature. Submit a copy of the signed, completed form(s) to DPI to the |
| |PI-PDP-3 (Rev. 12-09) |address below: |
| |(Initial Educators only) |DEPARTMENT OF PUBLIC INSTRUCTION |
| | |TEPDL |
| | |PO BOX 7841 |
| | |MADISON, WI 53707-7841 |
| | |Fax: (608) 264-9558 |
| | |INSTRUCTIONS TO PDP TEAM MEMBER: Complete Part II and return to educator. |
|Professional Development Plan (PDP) forms available at: | |
| | |
| |I. EDUCATOR INFORMATION | |
|Educator Name |Educator E-Mail Address |Educator File No.* |
| | | |
|LICENSURE CATEGORY Teacher Administrator Pupil Services |Date Goal Submitted to PDP Team |
| | |
|I HEREBY CERTIFY THAT, by my signature below, under penalty of perjury, that the information submitted by me in this form is true. I am aware that submitting |
|false information in connection with this process may result in non-approval and/or non-renewal of a license and may subject me to civil or criminal penalties. |
|Educator Signature |Date Signed |
|( | |
| |II. PDP TEAM MEMBER INFORMATION | |
|Team Member Name |Team Member E-Mail Address |Date Trained As a team member |Educator File No.* |
| | | | |
|Representing Check one |Check One |
|Teacher Pupil Services Administrator IHE |Goal Approved |
| |Not Approved |
|I HEREBY AFFIRM, by my signature, that the information provided is true and correct. | |
|Signature |Date Signed | |
|( | | |
|Team Member Name |Team Member E-Mail Address |Date Trained As a team member |Educator File No.* |
| | | | |
|Representing Check one |Check One |
|Teacher Pupil Services Administrator IHE |Goal Approved |
| |Not Approved |
|I HEREBY AFFIRM, by my signature, that the information provided is true and correct. | |
|Signature |Date Signed | |
|( | | |
|Team Member Name |Team Member E-Mail Address |Date Trained As a team member |Educator File No.* |
| | | | |
|Representing Check one |Check One |
|Teacher Pupil Services Administrator IHE |Goal Approved |
| |Not Approved |
|I HEREBY AFFIRM, by my signature, that the information provided is true and correct. | |
|Signature |Date Signed | |
|( | | |
*Educator file numbers may be found on the DPI Educator License lookup at:
|Note: The initial educator must have this form completed and signed by the PDP team. A copy of the signed form(s) must be submitted to the Department of Public |
|Instruction at the above address. Retain one copy for your own records. NO PAYMENT IS REQUIRED AT THIS TIME. |
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