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In-service_Course_Approval_Form

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					                              Nevada Department of Education
                             Request for In-Service Course Approval
Instructions:
1.              Submit application to the Department of Education at least thirty (30) working
                days prior to the beginning of the class. You may mail or email these forms as
                attachments to the address(s) listed. If the application is rejected, it will be returned
                with an explanation of deficiencies. When the course has been approved, the approval
                form will be returned to the authorized representative. The official course number will
                be listed on the certificate.

                Please mail this completed form to: James Kenyon
                Nevada Department of Education 9890 S. Maryland Pkway
                Las Vegas, Nevada 89183
                jkenyon@doe.nv.gov
                (702) 486-6489
                 Fax     (702) 486-6450
                                      Please submit electronically: Thanks
2.              When the course has been completed, please send the attached attendance sheet with
                dates, times, title of course, and names of attendees to the address listed above. The
                attendees should submit the certificates with their renewal forms.



School District or Agency:                                                    Date:

Address:
                Street                                   City                            State       Zip


Phone No.                                                Fax No.

Email:

Course Title:



Number of Credits Requested:

This course addresses Nevada’s K-12 content standards for:
                                                 English/Language             No Content Standard
     Math          Science      Social Studies          Arts                  addressed



(Standards are available on the NDE website at www.doe.nv.gov)
Please identify by subject and number those content standards that are addressed:




                                                         X
Print Name:                                              Signature of Authorized Representative:


For official use only:                                                        Date:



Approved by:                                                        Course Number:
                                                                                                 Posted 07/28/2011
                                              Request for Inservice
                                                Course Approval
                                               (Renewal Credits)
                                              Application Narrative


A Course Title:


B. Date(s) and Time(s) course is being offered. (Attach a daily schedule with breaks and meals clearly indicated,




C. Facility where course will be offered.

D.
     Address                                                           City                            State      Zip


E. Room Number:                                                        Estimated Enrollment:

F. Number of Credits requested:
     Note: To request one (1) renewal credit there must be 15 hours of instruction, excluding breaks. To receive one-

G. Faculty Member(s)

               1. Name(s) of proposed instructor(s) (Master Teacher, who should have at least a Master’s
                     a.
                     b.
                     c.

               2. Please attach a copy of instructor’s(s’) resume to this form. If any of the above are guest lecturers

               3. Name:

                 Address:

H. Course description:




I. The objectives of this course:
J. Method of Instruction:

             1. State which method(s) of instruction will be used (e.g. lecture, group discussion, demonstrations,




             2. List resources (books, handouts, tests, etc.) which will be used in the course:




K. Students:

                Who is eligible to enroll in the course?




                Any prerequisites?




L.
     Method of grading (e.g. examination, required assignments, participation, etc.). Please note that attendance is mandatory.
                 ATTENDANCE SHEET FOR INSERVICE CLASSES
(Please return this form to the State Department of Education, 9890 S. Maryland Pkwy #221, Las Vegas, NV
89183, at the conclusion of your course . This form may be duplicated)

Course Title: 0

Course No.       0                                                Date of Course:




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