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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

Verification of Paid Experience for Permanent Pupil Personnel Service (PPS) and Professional Classroom Teaching

Certificates

All paid experience for Permanent Pupil Personnel Service certificates and Professional Classroom Teaching certificates

must be verified by the Public School Superintendent, Chief School Officer of the Non-Public school or the Authorized

Official of a Speech and Language Disabilities provider.

Instructions for Certificate Holder:

Please complete Section I and submit the form to your employer(s) for completion of Section II. A separate form must

be completed by each employer.

Instructions for the Employer:

Please complete Section II and III. This form must be completed by the Superintendent of the school district or an

authorized individual, verifying that the certificate holder completed experience within the title of the certificate(s)

held. If the experience was part time, please indicate whether a. ,b. or c. was met and provide the number of full-time

equivalent days.

The form must be submitted to the Office of Teaching Initiatives by the employer via email to:

otiadmin@nysed.gov;

by mail to the address listed above:

Section I:

First Name:

Last Name:

Middle Initial:

Date of Birth:

Last 4 Digits of the Social Security Number:

_______ / _______ / _______

___________________

Certificate title(s) you are requesting this form be completed for:

Section II

For Permanent PPS certification, Commissioner's Regulations require two years of valid, paid, PPS work experience in

a public or approved non-public/independent school in the area of the title of the PPS certificate ( e.g. - School

Counselor, School Psychologist, School Social Worker, School Attendance Teacher, School Nurse Teacher, and School

Dental Hygienist Teacher).

For Professional teaching certification, Commissioner's Regulations require three years of acceptable paid teaching

experience in the certificate title (per 80-1) in a public or approved non-public/independent school. Experience as a

teaching assistant, aide, or paraprofessional is not applicable.

Name of school or employer:_______________________________________________________________________

Street Address:

City:

State:

Zip Code:

Employment 1

Position: ________________________________________________________________________________________

(Indicate title/subject and grade level)

Full-time:

from: ____/_____/_____

to _____/_____/____

Number of days ________

(mm)

(dd)

(yyyy)

(mm)

(dd)

(yyyy)

Part-time: full-time equivalent days: ________

from: ____/_____/_____

to _____/_____/____

(mm)

(dd)

(yyyy)

(mm)

(dd)

(yyyy)

a. For each school year, the experience averaged 2.5 days per week in the subject area and was completed in

periods of no less than 90 days.

b. For each school year, the experience included at least 45 days of part-time, continuous school experience

in the subject area and consisted of at least one class period each day with a consistent group of students

during such time period.

Form Ot 37 - Verification Of Paid Experience For Permanent Pupil Personnel Service (Pps) And Professional Classroom Teaching Certificates

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