Equivalency and In-Service Salary Credit
for Professional Development
REQUEST FOR PRIOR APPROVAL

Check one: _____ Already created PD activity   ______ PD activity you are creating

Name _______________________________   Date _____________________

School ______________________________   Position ___________________

Course Title/Activity _______________________________________________

Goal/Objective _____________________________________________________________

_________________________________________________________________________

Please describe how you expect this professional development will impact your work with
students. (I.e. What domains from Danielson or Learning Standards might be addressed.)

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Facilitator _________________________________________________________________

Location ______________________________________ Time ____________________

Type and Number of Credits    (in-service) ___________  (equivalency) _____________

Is this a Model Schools offering?  ______Yes      ______No

Dates to be taken ____________________________________________________________

Is this course being taken to meet Permanent Certification requirements of your tenure
area? YES/NO

Approved/Not Approved _______________________________ Date _____________
                                                          Principal/Director
Approved/Not Approved _______________________________ Date _____________
                                                          District Office

Please attach a copy of the course description (already created course) or a description
of the course you are creating.                                                                               10/03

Niskayuna Central School District
Equivalency and In-Service Salary Credit
for Professional Development

Request for Final Approval

Name _____________________________________  Date _______________________

Will this professional development actually impact your work with students? If so, how?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

As you reflect upon this experience, what might you do differently in the future?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Would you be willing to share your experience with other professionals in our district?

YES/NO   If so, how ________________________________________________________

_________________________________________________________________________

Would you recommend this course/activity to others? Why? Why not?

___________________________________________________________________________

___________________________________________________________________________

Type and Number of Credits          (in-service) __________   (equivalency) _________

I certify that I have successfully completed the approved professional development activity.

______________________________________ Date ________________________
                          Signature

Final Approval __________________________ Date ________________________
                                  District Office

Please attach a copy of the transcript or verification.