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Directions: Fill in this form as applicable to the Teacher Residency Implementation and Expansion Grant.

Important Notes:
  1. You may select any number of the residency areas listed below. The IHE partner(s) must have a Commission-approved program for each area selected.
  2. Estimate the target number of residents and the proposed per resident spending by credential or program type. Applicants may include a range of residents to be placed at an individual school site (e.g., 2-4 residents per year at XYZ school) if the sum of the maximum numbers in each range is equal to the total residents projected in the first table on this appendix.
  3. Projected residents should be counted only once on this table. For example, a program intending to recruit ten residents per year who are working toward an Education Specialist teaching credential and who may diversify the LEA’s teacher workforce will place the number 10 in the row titled “Diversifying Teacher Workforce that Reflects the LEA Community’s Diversity – Special Education.”
  4. It is expected that once residents obtain a preliminary teaching credential, the grantee will hire residents as teachers of record in a position that matches their residency training and in accordance with the local need outlined in the approved grant application. This is especially important for residents earning either a Multiple Subject or PK-3 ECE Specialist credential to teach TK or kindergarten. If the program is designed to prepare TK or kindergarten teachers, residents must be hired in those settings even though their credentials authorize them to teach other grade levels.
  5. Once the grant is submitted, residency areas cannot be changed, and annual resident projections may not be increased.
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1. Residency area, target number of residents annually, and proposed amount of grant funds per resident. Please fill out the following table.
Special Education
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
Special Education with Bilingual Authorization
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
Single Subject in a STEM Area
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
Single Subject in a STEM Area that Authorizes Teaching of Computer Science
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
Single Subject in a STEM Area with Bilingual Authorization
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
Single Subject Non-STEM with Bilingual Authorization
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
Multiple Subject (to teach in TK or Kindergarten)
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
PK-3 ECE Specialist Instruction Credential (to teach in TK or Kindergarten)
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
Multiple Subject with Bilingual Authorization
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
PK-3 ECE Specialist with Bilingual Authorization
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
Dual Credential
Please specify the two credentials here:
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
Diversifying Teacher Workforce that Reflects the LEA Community’s Diversity – Special Education
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
Diversifying Teacher Workforce that Reflects the LEA Community’s Diversity – Multiple Subjects and/or PK-3 ECE with or without added authorizations
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
Diversifying Teacher Workforce that Reflects the LEA Community’s Diversity – Single Subjects with or without added authorizations
Targeted Number of Residents Annually:
Proposed Amount of Grant Funds Per Resident:
2. Admission, enrollment, and clinical practice dates
Admission Date: Admission in a grant funded residency program is defined as the date when a candidate has been formally accepted into both the IHE and the LEA teacher residency program.
Date:
Enrollment Date: Enrollment in a grant funded residency program is defined as the date when a candidate has been formally admitted into the LEA teacher residency program and is registered in a required IHE course for the teacher residency program. The placement in the mentor teacher’s classroom may occur after the formal enrollment date.
Date:
Clinical Practice Start Date: Clinical Practice Enrollment in a grant funded teacher residency program is defined as the date when a resident has been formally assigned to a placement in a mentor teacher’s classroom. Note: the start date of the placement in the mentor teacher’s classroom must fall on or before the first day of classroom instruction.
Date:
3. LEA(s) and school sites where the residents would be placed. Please add rows if needed.

Applicants may include a range of residents to be placed at an individual school site (e.g., 2-4 residents per year at XYZ school) if the sum of the maximum numbers in each range is equal to the total residents projected in the first table on this appendix.

Information must be entered in the following format, with each LEA on a new line. DO NOT USE *** as this will become a new line.

5. Partner IHE(s) for the Teacher Residency Implementation and Expansion Grant.
Information must be entered in the following format, with each IHE on a new line. DO NOT USE *** as this will become a new line.
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