Stephanie Vasquez Ict Ctle Certificate

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The University of the State of New York

THE STATE EDUCATION DEPARTMENT


Office of Teaching Initiatives 89 Washington Avenue Albany, New York
12234
www.highered.nysed.gov/tcert

Completion of Approved Continuing Teacher and Leader Education (CTLE) Hour(s) Certificate
All CTLE must be completed with Approved Sponsors and be reported using this form in addition to any electronic
reporting requirements.
Instructions for the Trainee:

Please complete Section I and retain your copies for eight years. It is not necessary to send a copy of this form to the
Office of Teaching Initiatives unless it is requested in the event of an audit or for use in obtaining an Initial
Reissuance. ​A separate form must be completed for each training.

Instructions for the Approved CTLE Sponsor:

Please complete Sections II and III. These sections must be completed by the Approved CTLE Sponsor authorized
individual. Sponsors must verify that the trainee completed the activity, the title, date(s) and number of hours
awarded. Records must be retained for a period of eight years. You may use an alternative form or format, however
that alternative must capture the same information that is requested on this form.

Section I:
First Name:Stephanie Last Name: Vasquez Middle Initial:

Date of Birth: Last 4 Digits of the Social Security Number:


/ /
Section II

Name of Venue: CUNY


Street Address: 16 Court Street City:Brooklyn NY Zip Code:11201

CTLE Activity Title: ​Integrated Co-Teaching​ ​ ICT-Special Education

Select One or More Areas of Activity: Pedagogy Content English Language Learning

CTLE Date(s): from: 10 /24 /2018 to 10 /24 /_2018 Number of hours awarded ​ 6
(mm) (dd) (yyyy) (mm) (dd) (yyyy)

Section III
I certify that the individual listed in Section I completed the CTLE cited above pursuant to Subpart 80-6 of the
Regulations of the Commissioner of Education.

Approved Sponsor Name: ​ CUNY K-16

Print Name of Authorized Certifying Officer : ​ Lee Schere

Signature of Authorized Certifying Officer: ​Lee Schere

Approved Provider Identification Number:​23458 Date: ​ 10/24/2018


Email:[email protected] Phone #: ​ 718-254-7166
(Rev. 06/2016)

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