WEST VIRGINIA DEPARTMENT OF EDUCATION
Office of Title I
Building 6, Room 330
1900 Kanawha Boulevard, East
Charleston, West Virginia 25305-0330
APPLICATION FOR SUPPLEMENTAL EDUCATIONAL SERVICE PROVIDER
INSTRUCTIONS: Please review and follow all directions carefully when completing this application.
Type responses using 12-point font and double-spacing.
Adhere to page limitations. Applications that exceed page limits will not be considered. Attachments may be
Label and reference all attachments within the text of the application to enable evaluators to locate documentation
for the response. Attachments should be labeled with section number, letter, and item number (e.g., Section 3 A-
1). No supplemental material beyond what is specifically requested in the application will be considered.
Ascertain that all sections have been addressed in the application.
Acquire appropriate signatures for the assurance page.
If you have questions, contact Karen Davies, Ed. D., Title I School Improvement Coordinator, West Virginia
Department of Education by e-mail at email@example.com or by phone at (304) 558-7805.
Mailing Instructions: The application for the proceeding school year must be received at the WVDE office on or
before May 15 at 4:00 p.m. (for example, if May 15 is on a Saturday the application is due the Friday before). An
original and four copies of your application must be submitted. Faxed or e-mailed copies will NOT be accepted.
No amendments to the application will be accepted after this date. The application must be sent certified mail, return
Mail to: Karen Davies, Ed. D., Title I School Improvement Coordinator, West Virginia Department of Education, Building
6, Room 330, 1900 Kanawha Boulevard East, Charleston, West Virginia 25305-0330. The applicant must retain
documentation of the submission date.
Evaluation of application: Applications will be reviewed by a committee using uniform, objective criteria. Final approval
will be the decision of the review committee. Applicants will not be permitted to resubmit with corrections with the
exception of clarifications. No appeals process is available for those who are not approved. Applicants will be notified in
writing of their approval status.
SUPPLEMENTAL EDUCATIONAL SERVICES PROVIDER INFORMATION TYPE OF PROVIDER
Check all that apply
NAME AND ADDRESS OF SUPPLEMENTAL EDUCATIONAL SERVICES PROVIDER
(Include street, city, state, zip code) Include P.O. Box numbers, if applicable.
□ For-profit entity
□ Non-profit entity
If the location for the tutoring is different than the mailing address, please indicate.
□ Local Education Agency (LEA)
□ Regional Educational Service Agency
□ Private school
□ Faith-based organization
□ Individual (must be incorporated)
□ Community organization
FEIN or SOCIAL SECURITY NUMBER:
□ Institution of higher learning
□ Other __________________
NAME AND TITLE OF CONTACT PERSON TELEPHONE NUMBER (include area code)
FAX NUMBER (include area code)
E-MAIL ADDRESS WEBSITE HOURS OF OPERATION
SECTION 1 - SERVICE SUMMARY
Proposed Service Areas
If your services will be available for all eligible counties (LEAs) in West Virginia, check the box below. Otherwise, list
the county(ies) in which services will be offered.
All eligible counties/schools in West Virginia
Specific counties (list each county in which services will be offered):______________________________________
Basic Program Information
1. Supplemental Education Services will be available in the following subject(s) (check all that apply):
Reading Grade level(s) ________ Math Grade level(s) ________
2. Cost per hour per student $ ____________
Note: The LEA is limited in the amount of money it can spend to provide services for each eligible child. The
LEA is not required to provide funds for supplemental educational services beyond the minimum funding
requirement set forth in Federal law.
3. Minimum number of students provider is willing to serve: _________
Note: It is possible that only a few students will request services within a county.
4. Maximum number of students provider is able to serve: _________
5. Check the specific student population(s) in which the applicant will provide services (check all that apply):
Low achieving Migrant Learning disabled
Low income Minority Physically disabled
Limited English proficient students (if applicable, list languages):________________________________________
6. Check the location(s) that describes where services will be delivered to students (check all that apply):
School Business Place of Religious Worship Community Center
On-line Other _______________ (specify)
Note: If an applicant proposes to use a facility other than his or her own, a signed letter of agreement must be
submitted. Label the attachment as Section 1-6.
7. Check the time(s) that best describe(s) when services will be delivered to students (check all that apply):
Before School After School Weekends Summer
8. Will transportation for students be needed to the location of service delivery? Yes No
Note: Counties are not required to provide transportation for supplemental educational services.
If your services are not delivered at the school or online, will you provide site transportation? Yes No
9. Mode of Instructional Delivery (check all that apply):
Individual Tutoring Small Group Instruction Online/Web-based Other: _______________
List the ratio of students to instructor in your program. ________ students per one instructor
10. Is the student required to provide any instructional materials? No Yes If yes, list the materials:
SECTION II - PROGRAM DESCRIPTION
1. Provide a concise description of your program and services that may be used to portray your services to schools, parents, and
districts. Identify experiences with specific student populations served (e.g., low income, minority, special education, limited English
proficient and low achieving students). Other areas to address may include diagnostic processes, instructional techniques, program
equipment/materials, (including technology) and specific strategies used to evaluate the program effectiveness. The WVDE reserves
the right to edit the description based on additional information provided in the application.
SECTION III - INDICATORS OF QUALITY
The following measures will enable the West Virginia Department of Education to determine the quality of provided
services. For A-L below, submit a narrative response to address each statement. Type responses (12 pt. font, double-
spaced) and provide detailed explanations. Responses should be identified as A1; A2; A3; etc.for easy reference.
A. Evidence of Effectiveness (Limit 1 page for reading and mathematics combined)
1. Provide recent assessment data as evidence that your program has had a positive impact on student achievement
in reading and/or mathematics as measured by West Virginia State Assessment or nationally norm-referenced tests.
2. Provide evidence that demonstrates a positive impact on student achievement using a measure that is not a
national or statewide assessment (e.g., provider developed test, subject area tests or results of third party
3. Provide additional evidence of improved outcomes (e.g., attendance, retention/promotion rates, graduation rates).
Note that this evidence will be considered of secondary importance to the data submitted related to the improvement
of student achievement in reading and mathematics.
B. Evidence that program design is research based (Limit 3 pages)
1. Explain the theoretical and empirical research findings used to choose instructional strategies and determine the
selection of instructional materials utilized in your program. Independent research should be reviewed for specific
programs rather than the research provided by the developer of materials and programs.
2. Research should be high quality and include the five components of reading as well as high quality instructional
strategies for mathematics. Applicants should also consider providing research in the areas of student/teacher ratios,
modes of instruction, working with low-income/low achieving students, frequency/duration of tutoring sessions, etc.
3. Research citations must be provided.
C. Alignment to the West Virginia Content Standards and County and School Programs (Limit 1 page for each
1. Describe your program’s alignment to West Virginia content standards & objectives in reading and/or mathematics.
Give examples of specific standards/objectives that your program addresses.
2. Explain your program connection with the district(s) in which you plan to serve by citing specific district or school
programs and describing the connection. Identify the instructional materials that will be utilized, including the publisher
and date of publication.
Note: The West Virginia Content Standards are available at http://wvde.state.wv.us/policies/csos.html
D. Monitoring Student Progress (Limit 1 page)
1. Describe, in detail, the specific process used to access/diagnose student needs and skill deficiencies. Include the
name of any standardized test used for reporting pre/post test results.
2. Discuss the process used to prescribe an individual instructional program and develop specific goals in reading
and/or mathematics for the student.This must be completed in consultation with the student’s parent(s). Sample
forms used in the development of individual learning plans may be submitted as attachments.
3. Describe the method and the frequency of which student progress will be evaluated and monitored. Specify a
timetable for improving achievement.
E. Communication of Student Progress to the School and District (Limit 1 page plus attachments)
1. Identify the means of ensuring a connection exists between the school program and your services.
2. Describe the procedures used to report student goals and academic progress to the child’s classroom teacher(s)
and appropriate school and county staff. Specify the frequency of this procedure. Sample written progress reports or
communications with the school may be submitted as attachments.
F. Communication with Parents and Families (Limit 3 pages plus attachments)
1. Describe the procedures for explaining your services to parents and discuss how parents are involved in creating
goals for their child’s academic progress. All brochures that will be provided to parents must be included in this
section of the application (or submitted as an attachment) to be approved by the WVDE. (see L. page 5)
2. If the provider requires parents to participate in the service provided, explain the parent’s expected contribution.
3. Describe the training or professional development the provider staff receives in working with parents.
4. Describe the procedures used to report student progress to the students’ parents/families including the frequency
of this procedure (e.g., monthly, quarterly).
5. Describe how information is provided to parents and families in an understandable format and language.
6. Discuss the manner used to accommodate the needs and schedules of working parents.
7. Identify the process the provider will use for resolving disputes or conflicts between the parent and the provider.
8. Describe the procedures to assure federal and state student requirements (e.g., Family Educational Rights and
Privacy Act , FERPA) are met and that confidential student information is provided only to authorized persons.
Confidentiality agreements must be in place with parents, school district and the provider. A copy of this agreement
may be provided in the attachments.
G. Qualifications of Instructional Staff (Limit 2 pages plus attachments)
1. Describe your staff’s reading and/or math qualifications for providing supplemental services including training,
certification, related employment experience, professional development experiences and professional affiliations.
Be specific about your staff’s content knowledge in reading and/or math and their experience in working with Title I
students. Resumes of individual staff may be submitted as attachments.
2. Explain the orientation procedures that will be provided to your staff before beginning services with students as a
supplemental educational service provider.
3. Submit a professional development plan that outlines the ongoing professional development provided to your
staff to improve instruction and implement products and/or services. Include a description of the topics, timeline and
the number of hours of professional development required yearly for staff members.
4. Describe the procedures for recruiting and hiring competent staff. Background checks must be a part of this
procedure. (see I.1 page 5)
5. Discuss the procedures in place to evaluate instructional staff to ensure continued quality service. A formal
evaluation must be completed at least annually. Evaluation tools may be submitted as attachments.
H. Financial Soundness and Organizational Capacity (Limit 1 page plus attachments)
1. Submit evidence demonstrating that your organization is financially sound.
Evidence must include:
A copy of an audit report or an audited financial statement that has been completed within the last two years
and ensures no substantive findings were indicated that would compromise the financial soundness of the
Description of how the provider currently receives funds.
Proof of liability insurance (include company name and policy number, or a copy of the policy cover page.)
Evidence may include:
Credit ratings from an independent rating agency.
2. Submit evidence demonstrating that your organization possesses a sound management structure and adequate
organizational resources to successfully provide uninterrupted quality services for the term of the contract with the
Evidence must include:
A copy of a current business license or formal documentation of legal status for conducting business in West
Virginia. For further information contact the WV Secretary of State Office, Corporate Division at 304-
A description of procedures and/or sample forms used to document student enrollment, attendance, content
areas in which services are provided and student academic progress.
Evidence may include:
sample contracts or agreements for services provided.
A description of an experienced management team who is involved in setting direction and maintaining a
leadership system (e.g., CEO, Marketing Director,Director of Staff Development).
A copy of an organizational chart for your organization.
I. Compliance with Federal, State and Local Health and Safety Standards (Limit 1 page plus attachments)
1. Discuss your procedures for conducting required criminal background checks prior to hiring employees.
2. Submit a copy of all required licenses and/or certifications for health and safety (e.g., local or state fire
inspection certificate, health and sanitation inspection reports, Occupational Safety and Health report, OSHA).
3. Describe the location and environment in which your services are provided. Provide information concerning the
accessibility of the facility for persons with disabilities.
J. Compliance with Federal, State and Local Civil Rights Protection (Limit 1 page plus attachments)
1. Discuss the compliance with federal, state and local civil rights protection for employees. Submit a copy of
personnel policies demonstrating compliance with civil rights laws and regulations.
2. Discuss compliance with federal, state and local civil rights protection for students.
3. Describe how the provider offers instruction that is secular, neutral and non-ideological.
4. If applicable, describe how services will be provided to students with disabilities to comply with IDEA
(Individuals with Disabilities Education Act) and ADA (Americans with Disabilities Act). An inventory of
accommodations such as large print books, acoustical devices, closed caption screening, touch screen
computers, etc. may be submitted as an attachment.
K. Other Considerations (Limit 1 page)
Describe any other program considerations you would like reviewed. This section is optional, however, if the a
description of any type of program incentives must be included in this section for state approval.
L. Narrative Description of Program (Limit 5 pages)
Summarize your program in a narrative form that can be used to market (see F. 1 page 4) your service to schools,
parents or districts. All items in this narrative should have been provided to the WVDE for evaluation purposes in
the various sections above. The narrative should include a description of the following:
Qualifications of the staff and the model of instruction (see G. page 4)
Assessment and/or diagnosis of student needs (See D. page 3)
Development of an instructional program/intervention based on the student’s individual needs (see D. page 3)
Specific teaching strategies to assist Title I students in improving their achievement in reading and math (see
B. page 3)
The program facilities/equipment, including technology, computers and software (see K. page 5)
Instructional materials provided (and those the student is required to provide, if any) (see #10 page 2)
Specific strategies used to work with parents/families (see F. page 4)
Specific strategies used to work with school personnel (see E. pages 3-4)
Specific strategies to evaluate the program’s effectiveness in increasing student achievement (see A; D; E; F
Procedures for evaluating your program and reporting results to the WVDE
MONITORING AND REPORTING
In accordance with federal regulations, the LEA and SEA are required to monitor the quality and effectiveness of the
services offered by the approved provider. Monitoring will include, but not necessarily be limited to, a record of student
attendance, academic achievement of students receiving services, adherence to the terms and conditions of the contract
with the LEA and compliance with all assurances. Federal legislation requires that providers who fail to increase academic
proficiency of students served under this program for two consecutive years will be subject to withdrawal from the list of
approved providers. Any provider who fails to comply with the provider eligibility requirements, assurances, or
responsibilities of approved providers will be notified, in writing, of the allegations. The provider will have 10 days to file a
written response. The SEA will consider the response and shall make a final decision of the provider’s eligibility to remain
on the WV state approved SES list. A provider will be removed from the state approved list immediately if a threat exists
to the health or safety of students. Random site visits may be conducted as part of the monitoring process.
An annual performance report that summarizes the progress of the LEA’s students who have participated in supplemental
services must be completed and submitted to the LEA and SEA upon request. The report form will be provided by the
West Virginia Department of Education. This information will be reviewed and used for determination of provider eligibility
when annually updating the state approved list.
Assurance is made to the Title I Director of the West Virginia Department of Education that the supplemental educational
services provider will:
1. Ensure that background checks of all employees have been conducted and have produced no evidence of
criminal records. Records of employees must be made available to the State and Local Educational Agencies
2. Ensure that no disclosure to the public will be made of the identity of any student eligible to or receiving
supplemental educational services without the written permission of the parent/guardians of such students.
3. Ensure that accurate records are kept to document student enrollment, attendance, content areas in which
services are provided and progress made by individual students.
4. Ensure that all applicable Federal, State and local health, safety and civil rights laws are being met.
5. Ensure that all instruction and content are secular, neutral and non-ideological.
6. Ensure that instruction provided and materials used by the applicant are consistent with the instruction provided
and content used by local and State educational agencies and furthermore, are aligned with WV student
academic achievement standards.
7. Ensure that supplemental educational services are provided outside of the regular school day.
8. Ensure that the provider will not discriminate based on race, national origin, sex or disability in providing eligible
students with supplemental educational services under Title I.
9. Ensure that students with disabilities will be provided services that are consistent with the student’s individualized
education plan under section 614 of IDEA or Section 504 of the Rehabilitation Act of 1973.
10. Ensure that parent/guardians of students receiving supplemental educational services and the appropriate local
and state educational agencies are provided with information on the progress of the student in increasing
achievement on a timely basis and in a format and language that parent/guardians can understand.
11. Ensure that all provisions of the agreement between the provider and the local educational agency are fulfilled.
Failure to do so will render the agreement null and void.
12. Ensures that in accordance with federal regulations, the provider will cooperate with the LEA and SEA in
monitoring the quality and effectiveness of the services offered by the approved provider.
13. Ensures that an annual performance report that summarizes the progress of the LEA’s students who have
participated in supplemental services will be completed and submitted to the LEA and SEA upon request.
14. Ensures that the provider will submit written notification to the Title I office of the West Virginia Department of
Education when supplemental educational services can or will no longer be provided or available from the
I, the undersigned hereby certify that I am the individual authorized to act on behalf of the organization in submitting this
application and assurances. I certify that all the information herein is true and accurate, to the best of my knowledge. I
understand that if any of the information contained herein is found to have been deliberately misrepresented, that may
constitute grounds for denying the applicant’s request to be an approved supplemental educational service provider for
the State of West Virginia or for removal from that same list. Furthermore, I certify that this entity will comply with the
assurances set forth herein.
Name of Applicant or Organization
Signature of Supplemental Education Services Provider Official Date
Taken swore and subscribed on this ___________day of ______________________________ 20__.
Signature of Notary
My commission expires ____________________________________________.
* Revisions to the application are adapted from “Recommendations for Approving Supplemental Service Provider
Applications” (Version 1.3) developed by CCSSO.