APPLICATION
Technology Integration Specialist for Special Education
2010-2011
SUBMIT ALL FORMS TOGETHER AS ONE APPLICATION
BY APRIL 28, 2010.
Participant Information (Please type)
Special Education Teacher:
E-mail Address:
Home Phone:
Home Mailing Address:
Mobile Phone:
I am certified and hold endorsements in the following areas:
School:
District/Agency:
School Address:
School Phone Number:
Principal’s Name:
*Co-teaching is “when two professionals co-plan, co-instruct and co-assess a diverse group
of students in the same general education classroom” (Murawski, 2003).
February 17, 2016
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To be completed by the Special Education Teacher
Years of co-teaching experience:
Co-teaching content areas:
Please list the resources you currently use to integrate technology into your instruction.
Please describe how your deeper knowledge of technology integration will enhance the
achievement of all students in your classroom.
How do you envision your co-teaching and interaction with other staff at your school changing as
a result of participating in the Special Education Technology Integration Specialist initiative?
*Co-teaching is “when two professionals co-plan, co-instruct and co-assess a diverse group
of students in the same general education classroom” (Murawski, 2003).
February 17, 2016
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Statement of Assurances
If I am selected to participate in the Special Education Technology Integration
Initiative, 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.
Typed 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 TIS initiative.
I agree to accommodate the necessary release time and schedule to accomplish
the assurances.
Typed Name of Principal
Signature of Principal
Date
*Co-teaching is “when two professionals co-plan, co-instruct and co-assess a diverse group
of students in the same general education classroom” (Murawski, 2003).
February 17, 2016
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County Special Education Administrator
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.
Typed Name of County Special Education Administrator
Signature of County Special Education Administrator
Date
County Technology Contact
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 will
ensure that all equipment will be purchased and installed by October 1, 2010.
Typed Name of Technology Contact
Signature of Technology Contact
Date
*Co-teaching is “when two professionals co-plan, co-instruct and co-assess a diverse group
of students in the same general education classroom” (Murawski, 2003).
February 17, 2016
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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 Technology Integration SE-TIS
model at the district level to ensure successful implementation at the school site.
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 co-teaching 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 postsecondary outcomes; and
The County will make available the following support and assistance to the site:
 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.
 Ensure provision of additional monies to provide the required
technology.
 Ensure that the County Technology Contact supports this
professional development by participating in the acquisition of
required hardware and meets the October 1, 2010 deadline for
purchase and installation.
Typed Name and Title of County Superintendent
Signature
Date
*Co-teaching is “when two professionals co-plan, co-instruct and co-assess a diverse group
of students in the same general education classroom” (Murawski, 2003).
February 17, 2016
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Technology Integration Specialists for Special Education Initiative
Timeline for Application and Training
2010-2011
ACTION
Distribute information to Superintendents and
Chief Instructional Leaders
DATE
March 31, 2010
Applications for Special Education Technology
Integration Specialist (SE-TIS) available
April 1, 2010
Availability of opportunity posted on WVDE
website
April 1, 2010
Applications from SE-TIS and signed assurances
due to WVDE, Office of Special Programs
April 28, 2010
SE-TIS selected and notified of participation
May 5, 2010
Online participation
May 31, 2010 - June, 2011
Professional Development – Bridgeport
Conference Center
July 6-8, 2010
Professional Development – Charleston Civic
Center
August 2-5, 2010
Continuing Professional Development
On-going throughout school year as
scheduled. Will include face-to-face
workshops, online course(s) and other
professional growth activities.
*Co-teaching is “when two professionals co-plan, co-instruct and co-assess a diverse group
of students in the same general education classroom” (Murawski, 2003).
February 17, 2016
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Technology Integration Specialists for Special Education Initiative
Checklist for Application
2010-2011
□ Complete application form (available at http://wvde.state.wv.us/osp/SETIS.html or
http://wvde.state.wv.us/technology/tis)
□ Sign Assurances Form
□ Have principal, special education director, county technology contact and superintendent sign
Assurances Forms
□ Mail or fax completed application and signed Assurances by April 28
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.
*Co-teaching is “when two professionals co-plan, co-instruct and co-assess a diverse group
of students in the same general education classroom” (Murawski, 2003).
February 17, 2016
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