DATE:
NCLB-SES Program/Work Plan Form
Note: Please read instructions carefully . You must fill out all blue cells in this document. Your program/work plan must be
consistent with your State Approved Technical Proposal in all manner and form. Any deviation will be grounds for termination of
contract and will result in immediate recommendation to the State for removal of your organization from the State’s list of
Approved Providers.
PROVIDER’S LEGAL NAME (As listed on your NYSED approval)
You must fill out a separate Work Plan Form for each Line Item service listed in your Proposed
Estimated Annual Budget. Please select the appropriate Line Item from the drop-down list below by
clicking on the cell and then clicking on the triangle that appears to the right (you can scroll up and down
within the drop-down list to find the appropriate Line Item number).
LINE ITEM(s) HOURLY RATE (Note: your rate is to be accurate - do
not use the terms: "not to exceed" or "up to".)
STUDENTS (NOTE: DESCRIPTION MUST REFLECT NYSED APPROVED RFQ)
Grades Served?
Do you serve special education students?
Do you serve English Language Learners?
INSTRUCTORS (NOTE: DESCRIPTION MUST REFLECT NYSED APPROVED RFQ)
Please Describe - If insufficient space, use separate form and attach it to this excel spreadsheet)
Who is providing the tutoring? (e.g. certified
teacher, college student) Include a description of
instructional staff’s experience and
qualifications:
Certified Teacher to Instructor Ratio?
Instructor to Student Ratio?
METHODOLOGIES NOTE: DESCRIPTION MUST REFLECT NYSED APPROVED RFQ)
Instructional Method: (check all that apply) Please Describe:
Direct Instruction
Computer Assisted (not direct instruction)
Project Based
Workshop Model
Other
Method/materials to measure student progress
INSTRUCTIONAL PROGRAM NOTE: DESCRIPTION MUST REFLECT NYSED APPROVED
RFQ) Please Describe - If insufficient space, use separate form and attach it to this excel spreadsheet)
Please describe your instructional program:
(include details about how your program is consistent
with the NYCDOE curriculum in ELA/Reading
and/or Mathematics.)
If you are using a commercial program, please
identify and write a description from your
approved SED RFQ.
Do you intend to use incentives or rewards as
part of your SED approved program?
If so, please describe how and why these will be
used. (Attach that section of your approved
curriculum that you intend to implement)
INSTRUCTIONAL MATERIALS (material used by students during the program)
NOTE: DESCRIPTION MUST REFLECT NYSED APPROVED RFQ
Please Describe - If insufficient space, use separate form and attach it to this excel spreadsheet)
Instructional Material: (i.e., textbooks, workbooks,
periodicals, math manipulatives)
Instructional Equipment: (i.e., computers, calculators)
PROGRAM SCHEDULE (If you are working at an NYCDOE school and the school cannot accommodate your program for
the full schedule indicated here, you are required to contact the NCLB Implementation Director immediately and notify him/her of
any modification of your hours at that site. Modification must retain the integrity of your NYSED approved program otherwise you
cannot offer services at that site. The NCLB Implementation Director will review your modification and determine whether your
hour modification is consistent with the NYSED approval.)
Proposed Initiation Date for Program:
(Note: This date cannot be earlier than the NYCDOE's
annual NCLB-SES program start date)
A)Number of Sessions per week:
B)Number of Hours per session:
C)Number of Weeks for program:
Total Number of Hours for Year:
(Should be AxBxC above)
PROGRAM LOCATION(S): If anticipated site is a school, include the school name/school number and district number. If
an anticipated site is not NYCDOE school property, then you must submit a Certificate of Occupancy for that site. If you have
multiple addresses, please enumerate each separately (i.e., list as 1, 2, 3, 4, etc.)
Please List Addresses/School Name(s) and School District
Expected Locations (check all that apply):
Number(s):
DISTRICTS (AS APPROVED BY NYSED)
NYCDOE School Property
Storefront Location
Community Center
Other
ORGANIZATIONAL STRUCTURE
On a separate page, provide an organizational structure chart – make sure that you include the name and/or
position of the person and/or job title to whom the SES Director reports. Your organizational chart must
match your own company structure, not that of the sample. A sample organizational chart is available at:
http://schools.nyc.gov/OFFICES/DCP/NCLB/SampleOrgChart.PDF
Immediately below, please describe the roles and responsibilities of all SES staff listed on the organizational
TITLE ROLES/RESPONSIBILITIES
.
Yes
No
001 ELA/Reading Group Instruction
002 ELA/Reading Individual Instruction
005 Mathematics Group Instruction
006 Mathematics Individual Instruction
007 ELA/Reading/Math Group Instruction
008 ELA/Reading/Math Individual
009 Week-End ELA/Reading/Math Group
011 Week-End MATH Individual
012 Week-End ELA/Reading Individual
Instruction