DOUGHERTY COUNTY SCHOOL SYSTEM P.O. Box 3170 ● 200 Pine Avenue Albany, GA 31706-3170 (229) 431-1296 ● FAX (229) 431-1810

Request for Title IIA Funds Professional Development Prior Approval Form

Name of Administrator Requesting Prior Approval: ________________________________________ School/Department: _____________________________________Date of Request: ______________ Type of Professional Development: _____________________________________________________ Professional Development Date/s: _______________________ Location: _______________________ Professional Development Website Address: _____________________________________________ Total Amount Requested (include all applicable expenses: stipends, substitutes, lodging, registration, meals, mileage, etc.): _________________________________________________________________ Provide an estimate of each expense requested. Estimate(s) must equal the total requested above. Stipend: $________________________________ Lodging: $_______________________________ Registration: $____________________________

Registration Deadline: ______________________

Meals: $_________________________________

Mileage: $________________________________

Substitutes: $______________________________ Number of Subs Requested: _________________ Other: $__________________________________

Participation: Supervisors/Administrators must attach a typed list of the teachers including the school name, teacher employee number, social security number (non-employee only), and dates for service. Attach a detailed copy of an agenda outline with this prior approval. Professional Development Activity(s) Overview:

Please submit the following items within one week (7 days) to receive stipend and/or reimbursement: • Sign-in Sheets (original (DCSS) or copy if location is offsite provided by another entity) • Additional Compensation Agreement (two weeks prior to beginning of work-no exceptions) and Monthly Payroll Timesheet(original) • Expense statement with all receipts attached • Copy of documentation from professional development (handouts, certificate of completion, PowerPoint, agenda received from PD site, etc.)

Note: Forward the originals to the Title IIA Secretary and retain a copy for your records.

Forty-five (45) days advance notice must be given for prior approval. Approval must be granted by Title II-A Coordinator before any professional development begins. All items needed for stipend to be paid must be turned in no later than one week (7 days) after completion of professional development. If at DCSS location, all participants must have their badge so that they can swipe in and out daily (includes lunch break); no exceptions are granted. Expense statements (typed only; no hand written will be accepted) with all documentation requested need to be submitted to the Title IIA secretary with one week (7 days) of return for reimbursement. Person requesting prior approval is responsible for submitting sign-in sheets. For any registration fees, verify that vendor is already a DCSS vendor so that it will not delay payment process. If not, you are responsible for having them to complete vendor application and submitting back to the Title IIA secretary. I have read and fully understand that all of the above requirements must be meet and all documents are to be submitted before receiving the stipend payment. Also, DCSS holds the right to approve or deny stipend payments if the above requirements has not been followed.

_______________________________________________

_______________________

Administrator’s Signature: ________________________________________________________ Title II-A Coordinator’s Signature:

Date: ___________________________ Date:

_______________________________________________

_______________________

Associate Superintendent for Academic Services’ Signature:

Date:

Funding Source: Title II-A

Approved: __________ Disapproved: _____________

Disclaimer: The Dougherty County School System is an Equal Opportunity Employer and does not discriminate on the basis of color, race, national origin, age, sex, religion or disability. Note: Please submit the original signed form. A scanned copy of the approved or unapproved appropriate action taken will be emailed to the requestor. *All required information on this form must be completed prior to approval.

Title IIA: Teacher/Administrator Participation List

Teacher/Administrator Name

Employee Number

Social Security Number (non-employee only)

School Name

Dates for Services

Title IIA: Teacher/Administrator Participation List

Teacher/Administrator Name

Employee Number

Social Security Number (non-employee only

School Name

Dates for Services

Title IIA: Teacher/Administrator Participation List

Teacher/Administrator Name

Employee Number

Social Security Number (non-employee only

School Name

Dates for Services