This form is to be used for all relevant activities where documentation is not provided for completion of activity (i.e., certificates of attendance, certificates of completion, awarded CEU form, etc.)

Name:	District:

Check an activity from the list below and provide the requested information about the activity in the provided space.

Complete the line for Number of CEUs requested for selected activity.

Sign and date the form.

Include completed form with other CEU documentation at time of license renewal. (See Educator Renewal Instructions found on the Mercer County ESC website: www.mercercountyesc.org, under Services>Licensure/LPDC )

Use a new form for each selected activity.

Select One	Activity	CEU Calculation	Max. CEUs per license cycle	Provide following documentation
Virtual PD sessions	1 clock hour= 0.1 CEU	1.0 CEU per license cycle	Include reference of date and length of time. Administrator signature.
Book Study	1 clock hour= 0.1 CEU	18.0 CEUs	Name of book, hours spent at administrator-led meetings, Administrator signature.
Mentoring	6 CEUs per license cycle	2 CEUs per experience	Name of teacher mentored, date & Administrator signature.
Curriculum Development Committee	1 clock hour= 0.1 CEU	18.0 CEUs	Name of committee, starting & ending dates, number of hours spent on committee work. Administrator signature.
Professional Committee	1 clock hour= 0.1 CEU	18.0 CEUs	Name of committee, starting & ending dates, number of hours spent on committee work. Administrator signature.
National Board of Professional Teaching Standards	No Limit	18 CEUs= successful completion; up to 6 CEUs= partial completion	Partial completion: document providing: starting and ending dates, number of hours involved in preparation. (National Board Certificate for successful completion.)
Professional Vocational Board Certification	No Limit	18.0 CEUs= successful completion; up to 6 CEUs= partial completion	Partial completion: document providing: number of hours involved in coursework/clinic for test preparation purposes only. (Certificate for completion.)
Cooperating Teacher for a Student Teacher	9 CEUs per license cycle	3 CEUs per experience	Name of teacher supervised, their college, date (i.e. Fall of 2018). Administrator signature.
Internship Supervisor for an Intern School Psychologist/ School Counselor/ SLP	9 CEUs per license cycle	3 CEUs per experience	Name of intern supervised, their college, date (i.e. Fall of 2018). Administrator signature.
Cooperating Educator for a Practicum Educator	3 CEUs per license cycle	1 CEU per experience	Name of educator supervised, their college, date (i.e. Fall of 2018). Administrator signature.
Teaching a College Course	6 CEUs per license cycle	2 CEUs per course	Documentation of: College, Course, Date and Instructor of Record Status.
Vocational Externship	6 CEUs per license cycle	1 clock hour = 0.1 CEU	Employer for externship, dates, number of hours spent in externship.
Publication	No Limit	6 CEUs= book 3 CEUs = article	Title of article/book, publication date (must be commercially published), copy of the publication.
Professional Presentation	1.0 CEU per license cycle	1 clock hour = 0.1 CEU	Title & date of presentation, venue, and number of hours spent in preparation and presentation.

Provide Documentation Below:	Number of CEUs requested for selected activity:	CEUs

Administrator’s Signature (if required, see above):	Date:

Educator Signature:	Date: