Statement of Assurances
Technology Integration Specialist for Special Education
2011-2012
SUBMIT ALL FORMS TOGETHER
BY APRIL 11, 2011.
Applicant
If I am selected to participate in the Special Education Technology Integration Initiative
(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 21st Century 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 schedule the above named teacher in a co-teaching classroom and provide
the co-teaching team with common planning time to ensure the successful
implementation of this initiative. I agree to work with county administrators to fund the
purchase of technology (electronic whiteboard, data projector, and color printer/scanner)
required for participating in the SE-TIS initiative. I agree to accommodate the necessary
release time and schedule to accomplish the assurances.
Printed Name of Principal
Signature of Principal
February 12, 2016
Date
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County Special Education Administrator
Equipment required for SE-TIS:
 Electronic whiteboard
 Data projector
 Scanner (may be part of a combination unit)
 Color printer (may be part of a combination unit)
I agree to support the teacher and the school by assisting the school in obtaining and
coordinating the resources necessary to implement the initiative, 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
Equipment required for SE-TIS:
 Electronic whiteboard
 Data projector
 Scanner (may be part of a combination unit)
 Color printer (may be part of a combination unit)
I hereby give my assurances that I support the requirements for the Technology
Integration Specialist – Special Education initiative. I agree to accommodate the
necessary equipment purchases in order to accomplish the assurances. I also will
ensure that all equipment will be purchased and installed by October 3, 2011.
Printed Name of Technology Contact
Signature of Technology Contact
February 12, 2016
Date
2
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 County 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 21st century skills for all students
to improve their academic achievement and post-secondary outcomes; and
The County will make available the following support and assistance to the site:
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Utilize grant funds provided by the WVDE for 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.
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Ensure provision of additional monies to provide the required technology.
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Ensure that the County Technology Administrator supports this professional
development by participating in the acquisition of required hardware and
meets the October 3, 2011 deadline for purchase and installation.
Printed Name of County Superintendent
Signature
February 12, 2016
Date
3
Special Education Technology Integration Specialists
Timeline for Application and Training
2011-2012
ACTION
Distribute information to Superintendents and
Chief Instructional Leaders
DATE
March 4, 2011
Applications for Special Education Technology
Integration Specialist (SE-TIS) available
March 7, 2011
Availability of opportunity posted on WVDE
website and special education teachers’ listserv
March 7, 2011
Applications from SE-TIS and signed assurances
due to WVDE, Office of Special Programs
April 11, 2011
SE-TIS selected and notified of participation
May 4, 2011
Online participation
June, 2011 - June,2012
Professional Development – Waterfront Hotel,
Morgantown, WV
June 21-23, 2011
Professional Development – Waterfront Hotel,
Morgantown, WV
August 1-5, 2011
Continuing Professional Development
On-going throughout school year as
scheduled. Will include face-to-face
workshops, online course(s) and other
professional growth activities.
February 12, 2016
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Technology Integration Specialists for Special Education Initiative
Checklist for Application
2011 - 2012
□ Complete application form available at http://wvde.state.wv.us/osp/SETIS.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 by April 11
th
to:
Valerie Wilson
West Virginia Department of Education
Building 6, Room 304
1900 Kanawha Blvd, East
Charleston, WV 25305 – 0330
FAX: 304-558-3741
Please contact Valerie Wilson at vwilson@access.k12.wv.us or 304-558-2696 for further
information regarding the Special Education Technology Integration Specialist initiative.
February 12, 2016
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