Statement of Assurances
Technology Integration Specialist for Special Education
2016-2017
SUBMIT ALL FORMS TOGETHER BY APRIL 25, 2016.
Applicant
If I am selected to participate in the Special Education Technology Integration Program (SE-TIS), I
hereby give my assurances that I will:
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Participate in and successfully complete the 40 days (or 320 hours) of required
professional development;
Use my acquired technology integration skills to improve instruction for students with
disabilities and other students in the general education classes to which I am assigned;
Use my enhanced knowledge and skills to build effective co-teaching relationships;
Utilize collaborative planning time to assist in integrating technology into the instructional
units being planned;
Be a resource to other educators on technology integration as appropriate and as
instructional duties allow; and
Communicate the importance of developing technology skills in all students, including
those with disabilities, to improve their academic achievement and post-secondary
outcomes.
Printed Name of Special Education Teacher
Signature of Special Education Teacher
Date
Administrator Statement of Assurances
Building Principal
I agree to work with county administrators to purchase any needed technology for the applicant
to participate in the program. Participants are required to have a professional grade Notebook,
no more than 2 years old (PC or Mac) that connects with high speed Internet access to public
networks and district LAN. Operating system must be Windows 7 or newer for PC and the latest
version iOS for Macs. Notebooks must have internal or external video cameras and professional
productivity software. Participants need a headset with microphone. I agree to accommodate
the necessary release time and schedule 8 hours of staff training, with the SE-TIS candidate as
instructor, to ensure the successful implementation of this program.
Printed Name of Principal
Signature of Principal
February 29, 2016
Date
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County Special Education Administrator
The equipment required for SE-TIS is a professional grade Notebook, no more than 2 years old
(PC or Mac) that connects with high speed Internet access to public networks and district LAN.
Operating system must be Windows 7 or newer for PC and the latest version iOS for Macs.
Notebooks need to have internal or external video cameras and professional productivity
software. Participants need a headset with microphone.
I agree to support the teacher and the school by assisting the school in coordinating the grant
funding necessary to implement the program, including the provision of additional monies, if
necessary, to provide the required technology and/or defray the expenses associated with the
required professional development.
Printed Name of County Special Education Administrator
Signature of County Special Education Administrator
Date
County Technology Administrator
The equipment required for SE-TIS is a professional grade Notebook, no more than 2 years old
(PC or Mac) that connects with high speed Internet access to public networks and district LAN.
Operating system must be Windows 7 or newer for PC and the latest version iOS for Macs.
Notebooks need to have internal or external video cameras and professional productivity
software. Participants need a headset with microphone.
I hereby give my assurances that I support the requirements for the Technology Integration
Specialist – Special Education program. I agree to accommodate the necessary equipment
purchases in order to accomplish the assurances. I also will ensure that the needed equipment
will be available for use by June 10, 2016.
Printed Name of Technology Contact
Signature of Technology Contact
February 29, 2016
Date
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Superintendent Assurance Statement and Agreement
For the purposes of implementing the provisions of the Special Education Technology
Integration Specialists (SE-TIS) initiative, our County assures that:
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The district will support implementation of the SE-TIS model at the district level to ensure
successful implementation at the school site.
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The District understands and supports the participant’s requirements as follows:
 Participate in and successfully complete the 40 days (320 hours) of required
professional development (includes both online and face-to-face sessions);
 Use acquired technology integration skills to improve instruction for
students;
 Use enhanced knowledge and skills to build effective consultative and coteaching relationships with all teachers;
 Utilize collaborative planning time to assist in integrating technology into the
instructional units;
 Be a resource to educators on technology integration, as appropriate, in the
implementation of information literacy, independent learning and social
responsibility;
 Communicate the importance of developing technology skills for all students
to improve their academic achievement and post-secondary outcomes; and
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The District will make available the following support and assistance to the site:
 Utilize grant funds provided by the WVDE for equipment, travel and other
expenses for selected Special Education teachers to attend professional
development and ensure additional monies, if necessary, to defray the
expenses associated with the required professional development.
 Ensure that the County Technology Administrator supports this professional
development by participating in the acquisition of required hardware by
June 10, 2016.
Printed Name of County Superintendent
Signature
February 29, 2016
Date
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Special Education Technology Integration Specialists
Timeline for Application and Training
2016-2017
ACTION
Distribute information to Superintendents and
Chief Instructional Leaders
DATE
March 4, 2016
Applications for Special Education Technology
Integration Specialist (SE-TIS) available
March 9, 2016
Availability of opportunity posted on WVDE
website and special education teachers’ listserv
March 11, 2016
Applications from SE-TIS and signed assurances
due to WVDE, Office of Technology Integration
and Support
April 25, 2016
SE-TIS selected and notified of participation
May 13, 2016
Online participation
June, 2016 - June, 2017
Professional Development – Tamarack, Beckley,
WV
June 14 - 16, 2016
Professional Development – Waterfront Hotel,
Morgantown, WV
July 18 – 22, 2016
Continuing Professional Development
On-going throughout school year as
scheduled. Will include one face-to-face
workshop, online course(s) and other
professional growth activities.
February 29, 2016
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Technology Integration Specialists for Special Education Program
Checklist for Application
2016 - 2017
□ Complete application form available at http://wvde.state.wv.us/osp/SETISAPPLY.html
□ Sign the Assurances Form
□ Have your principal, special education director, county technology administrator and
superintendent sign the Assurances Forms
□ Mail or fax completed Assurances with your application by April 25, 2016 to:
Valerie Wilson
West Virginia Department of Education
Building 6, Room 825
1900 Kanawha Blvd, East
Charleston, WV 25305 – 0330
FAX: 304-558-2584
Please contact Valerie Wilson at vwilson@k12.wv.us or 304-558-2696 for further information
regarding the Special Education Technology Integration Specialist Program.
February 29, 2016
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