Please note that this is a SAMPLE certificate only;
districts may alter the format and/or language as it
relates to the requirements met in deeming their
teachers Highly Qualified. It has always been the
expectation of the Department that districts have been
providing documentation to educators denoting their
Highly Qualified status. In addition, NCLB requires
principals to keep an attestation on file confirming the
Highly Qualified status of each of the teachers in their
school(s).
Highly Qualified Status Certificate
Teacher Name_____________________________ District Name/State: ____________________________
Active/Valid Teaching License(s)/Certificate(s) _______________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Core academic subject(s), taught by any teacher, including special education and ESL teachers, for which the
teacher has met the criteria to be designated Highly Qualified (Check all that apply):
_____ elementary subjects (math, science, English/reading/ELA, history/social studies)
_____ science (specify subject(s): _____________________________________________________)
_____ the arts (Visual Art, Music, Theater, Dance)(specify subject(s):______________________________________)
_____ foreign language (specify language(s): ___________________________________________)
_____ English
_____ reading/language arts
_____ math
_____ history
_____ geography
_____ economics
_____ civics and government
_______________________________________ has been deemed “Highly Qualified” in the above indicated core
(Teacher Name)
academic subjects
/
(Teacher Signature)
/
(Date)
(Principal Signature)
(Date)