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									Application No.                                 Application for New AWE Credential/Certificate Program       Date 1st Reviewed BOR:
                                                                 Ohio Board of Regents                       Date Returned to Sender:
                                                              Adult Workforce Education                      Date Revision Received:
                                                                                                             Date Approved BOR:

Institution Name:                                                                             Date Submitted:

Address:                   #N/A                                                               City           #N/A                       Zip   #N/A

District IRN:              #N/A          CTPD # :       #N/A          Website Address:        #N/A

REQUEST SUBMITTED BY

Name:                                                                 Title:

Phone Number/Extension:                                               Email address:

PRIMARY CONTACT FOR THE PROGRAM

Name:                                                                 Title:

Phone Number/Extension:                                               Email address:

PROGRAM INFORMATION

Program Title:                                                                                Clock Hours:               Number of Weeks:

Subject Code:                                                                                 Proposed Start Date:

Classification of Instruction Code (CIP):
Standard Occupational Classification (SOC) System:

Is This an Apprenticeship Program?

Click here to go to Submission Information section
    SUBMISSION INFORMATION                                                           Meets Criteria


    For a program to be considered for approval, the following
    criteria must be addressed. Respond in the space provided.
    Remember to save the document as you work through the
    questions.

    CRITERIA

    Justification of Need and Stakeholder Input

1 Provide justification for program need including local labor market data,
  employer need for the program and projected job openings within a 30 mile
  radius of your institution.




2
    Identify where similar programs in your geographic area are taught and how
    this program will be different or will serve a unique need or target audience.




3 Has an advisory committee been established for this program?



    If yes, list advisory committee member names and the company they
    represent.
    Click here for template
  Program Information, Delivery and Design

4 Identify the Program goals and objectives.




5 Are there pre-requisite courses or other student enrollment qualifying
  criteria?



  If yes, identify the pre-requisites.




6 Is a student/teacher ratio required by a regulatory entity, credentialing entity,
  program accreditation entity or other?



  If yes, identify the ratio and why.




7 Identify the projected enrollment for the proposed program during the first
  year of operation.




8 Will this program be operated in conjunction with another adult career center
  or college?



  If yes, do you have a signed contract or MOU with the adult career center or
  college?


  If yes, attach a copy of the signed contract or MOU to the email submission of
  this document.
 9 Identify the method of program delivery. Check all that apply.
       Traditional Program that consists of classroom (face-to-face) and lab.
       Hybrid program that blends online, face-to-face and lab.
       Other method of program delivery.

   If other, describe method of program delivery.


   Identify percent of program delivered in each area.
   Classroom %:


   Online %:


   Lab %:


   Clinical %:


   Experiential based learning %:




   Curriculum Design

10 Provide a curriculum outline that defines the major curricular topics by
   completing the template. Include hours for clinical and experiential based
   learning as applicable.
   Complete this template. An example is included.




11 Describe how academics are integrated into the curriculum.
12 Identify the ACT WorkKeys Assessment Levels for:
     Applied Mathematics (AM):


     Locating Information (LI):


     Reading for Information (RI):


     Identify other WorkKeys assessments and their levels.


     Describe how the levels were determined.




13 Is experiential based learning a component of this program?



     If yes, describe.




     Industry Credentials/Program Approval

14
     Identify the OBR approved industry certification(s) your students could earn
     upon successful completion of the program by completing included template.
     Click here for template




15
     If you would like to offer an industry certification that is not on the approved
     OBR list, use the template below to identify the name of the certifying entity,
     the name of the certification, and their web address.
     Click here for template
16 Does this industry credential require that any or all of the following be
   approved by the certifying entity: Program; facilities; curriculum; or teacher?
   (i.e. NCCER, ASE, etc.)



   If yes, identify the entity and attach a copy of the approval letter to the
   submission email.




17 Does this program require approval from an external regulatory entity? (i.e.
   State Board of Nursing, State Board of Cosmetology)



   If yes, identify the entity and attach a copy of the approval letter to the email
   submission of this document.




   Transition Strategies

18 Is this program CT2 eligible?



   If yes, have you submitted an application?


   What is the application status?


   If approved, identify the courses and credit hours by completing included
   template.
   Click here for template

   If no, and if applicable, describe your plans to submit an application. Include a
   timeline.
19 Is there a bi-lateral agreement with a college for this program?




     If yes, list the courses and credit hours by completing included template.
     Click here for template




     If no, if applicable, describe your plans to pursue an articulation agreement.
     Include a timeline.




20
     Describe what you will do to assist the student's transition into the workforce.




     Ancillary Student Services

21
     Describe the support services available for students to assist them in being
     successful in this program. (i.e. academic counseling, tutoring, career services)




22 Describe the services available for students who are identified as special
   populations. (As defined by Perkins legislation.)




     Budget

23
     Complete a start-up operating budget for the first year of the program.
     Click here for template.
   Marketing and Promotion

24 Describe how this program will be promoted to potential students.




25 Provide the course description as written in your course catalog.




   Additional Comments

26 Provide any comments you would like to make that are relevant to this
   application.




   Questions:
   Contact Carolyn Gasiorek
   cgasiorek@regents.state.oh.us
   614-644-6661


   To submit application:
   1. Save this document
   2. E-mail as an attachment to Carolyn Gasiorek:
                           cgasiorek@regents.state.oh.us
                                                Curriculum Design Example
Program Title: Medical Office Administration
                                     Topic                                  Theory   Lab   Clinical   Other
Medical terminology                                                           35
Medical coding and billing                                                    30     20
Electronic health records                                                     20     40
Electronic billing                                                            15     20
Database management                                                           20     30
Externship                                                                                             200
TOTAL                                                                        120     110      0        200

Click here to return to question
                                               Curriculum Design Template
Program Title:



                                    Topic                                   Theory   Lab   Clinical   Other




TOTAL                                                                         0       0       0         0
3. Has an advisory committee been established for this program?
Click to return to question
                                  Name                            Company/Agency
14. Identify the industry certification(s) your students could earn upon successful completion of the program.
Click here to return to question
                               Industry Credential                                                        Name of Certifying Entity
15.For certifications not on the OBR approved list, provide the name of the certifying entity, the industry credential name and web address for verification
and consideration for approval.
Click here to return to question
         Name of Certifying Entity and Name of Industry Credential                                              Website Address
18. If approved, identify the courses and credit hours by completing included template.
Click here to return to question
                            College and Course Title                                      Credit Hours
19. If yes, list the courses and credit hours by completing included template.
Click here to return to question
                             College and Course Title                            Credit Hours
                                                       BUDGET TEMPLATE
Click here to return to question
PROGRAM TITLE:
DATE:

Revenue:                                                             Expenses:
EXAMPLE: Tuition - Adult            $       101,250                            SALARIES & BENEFITS:
EXAMPLE: Other Revenue              $        26,010                  EXAMPLE: Regular Cert               $   65,860
                                                                     EXAMPLE: Benefits                   $   17,980




            REVENUE TOTAL           $           -
                                                                           SALARIES & BENEFITS TOTAL     $      -
                                                                               PURCHASED SERVICES
                                                                     EXAMPLE: Technical Services         $    8,490




Tuition based upon:
EXAMPLE:                                                                   PURCHASED SERVICES TOTAL      $      -
Students                                          15                           SUPPLIES & MATERIALS
Tuition                             $         6,750                  EXAMPLE: Instructional Supplies     $   22,930
Total                               $       101,250                  Books                               $    2,240
Students                                                             Tools                               $    2,670
Tuition
Total                               $           -



Supplies/Materials/Books: (Other Revenue)
EXAMPLE:                                                                  SUPPLIES AND MATERIALS TOTAL   $      -
Students                                          15                 SUBTOTAL EXPENSES                   $      -
Cost (Sup/Mat/Books)                $         1,734                  % Administrative Cost (ex. 20%)
Total                               $        26,010                  Administrative Cost                 $      -
Students                                                             TOTAL EXPENSES PLUS ADMIN COST      $      -
Cost
Total                               $           -


TOTAL REVENUE LESS EXPENSES = NET INCOME
REVENUE                              $          -
EXPENSES                             $          -
NET INCOME                           $          -

								
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