Internal CUHSD Course Approval Form
Site: _____________________________Department:______________________ Department Chair: __________________________
Date Submitted: ______________________________ Approved By (Department Chair Signature): ____________________________
□ Approved By (Principal Signature)_____________________________ □ Not Approved (Rationale): ________________________
District Use Only:
Date Received and Signature by Educational Services Dept.: _____________________________________________________________________
Date Submitted and Signature from Human Resources Department (credential verification): ___________________________________________
Date Board Approved: ______________________________________Date Submitted to ITG: _________________________________________
Date Course Created: _____________________________________ Course Created By: _____________________________________________
CSIS/CBEDS Assignment Code: ___________________________ Short/Long Description: _____________________________________________
Please Check One:
 Final Approval-Date and Signature of Asst. Supt. Ed. Services: __________________________________________________________________
 Not Approved/Reason: _________________________________________________________________________________________________
 Under Review/Reason: _________________________________________________________________________________________________
Fall 2014
Please check one (continued on next page):
☐ New course to district (stand alone, not part of a district approved pathway sequence currently in district)
☐ New course in a currently existing pathway in the district (part of an adopted pathway/sequence… i.e.: PLTW, AG, World Lang)
☐ Approved at another school in district, but requesting approval to offer/activate at our site
☐ Approval to offer/re-activate an inactive course or pathway sequence
☐ *Check this box if the new course is the initial course in a new pathway sequence. Request to approve entire sequence.
Course Title: (if currently offered at another site please attach syllabus &
textbook information)
Transcript Title(s)/Abbreviation(s) for Aeries:
Transcript Course Code(s)/Number(s):
School(s):
Fall Code:
Spring Code:
Subject Area:
☐History/Social Science
☐ English
☐ Visual & Performing Arts
☐ Mathematics
☐ Laboratory Science
☐ Language other than English
☐ Career Technical Education
☐ College Prep Elective
Primary Department:
Grade Level(s): ☐ 9
☐ 10
☐ 11
☐ 12
Select One: ☐ General Ed
☐ Special Ed
Fall 2014
☐ ROP
☐ Honors
☐ AP
☐ ELD
☐ Core Subject Area Support Class
Credit Value:
☐ 5 (half year or semester equivalent)
☐ 10 (one year equivalent)
Is this an Internet-based course?
☐ Yes
If “Yes”, who is the provider?
☐ UCCP ☐ PASS/Cyber High
☐ Other: ___________________
☐ No
Pre-Requisites:
Co-Requisites:
Brief Course Description:
(Note if course is repeatable for credit, ie: Marching Band or PE)
Fall 2014
☐ 20 (two year equivalent)
☐ Edmentum
☐ BYU
☐ Udacity
☐ Other___________________
Texts & Supplemental Instructional Materials
Title:_______________________________________________
Select One:
Publisher: ___________________________________________ Select One:
☐ Core
☐ Supplemental
☐ New* ☐ Currently on Instructional Materials List
ISBN:_______________________________________________ If ELA, H/SS, or Science, is there an EL Component?
Copyright Date: ______________________________________
☐ Yes
☐ No
Funding Source: _________________________________________________
* If course is new, please explain the process and timeline for standards mapping, pilot/review, legal and social compliance,
proposed board approval. (If text is not new, please attach number of texts from Destiny):
Title:_______________________________________________
Select One:
Publisher: ___________________________________________ Select One:
☐ Core
☐ Supplemental
☐ New* ☐ Currently on Instructional Materials List
ISBN:_______________________________________________ If ELA, H/SS, or Science, is there an EL Component?
Copyright Date: ______________________________________
☐ Yes
☐ No
Funding Source: _________________________________________________
* If text is new, please explain the process and timeline for standards mapping, pilot/review, legal and social compliance, proposed
board approval: (Please duplicate this box if more materials are needed).
Title:_______________________________________________
Fall 2014
Select One:
☐ Core
☐ Supplemental
Publisher: ___________________________________________ Select One:
☐ New* ☐ Currently on Instructional Materials List
ISBN:_______________________________________________ If ELA, H/SS, or Science, is there an EL Component?
Copyright Date: ______________________________________
☐ Yes
☐ No
Funding Source: _________________________________________________
* If text is new, please explain the process and timeline for standards mapping, pilot/review, legal and social compliance, proposed
board approval:
Part 2: Following UC Doorways Approval, please attach:
☐ UC Doorways Page
☐ Date of Submission
☐ Date of Approval
☐ Uploaded Course Syllabus
Part 3: Alignment to LCAP, LEA, Site Plan and WASC Action Plan
Please delineate below how this course helps the site and district reach its designated student achievement goals [specify to which
of the 8 state priorities and district goals this course aligns, in addition to your site WASC/site plans]
Part 4: Fiscal Impact to Site and District
☐ No Fiscal Impact
☐ Additional Funding Needed/Anticipated [Please project staffing, facility and instructional materials impact]
Fall 2014
Fall 2014