Continuing Teacher and Leader Education (CTLE) Individual Record

Directions: This form is provided for use by individuals holding either a Professional Certificate or a Teaching Assistant Level III certificate. This document will assist CTLE certificate holders with maintaining records of CTLE activities in accordance with certification regulations.

1.	Document activities in the table below.
2.	Keep “Certificate of Completion” forms and/or other documentation with this record. Documentation must be retained for 8 years.
3.	DO NOT submit this form or other CTLE documentation to the Office of Teaching Initiatives, unless it is requested. At the end of your Registration period, you will be asked to attest to meeting or not having met CTLE requirements. This document will assist you with making the proper determination.

Name:
	DOB:
	Last 4 of SSN:
	
Certificate Title(s):
	
Five-Year Registration Period (See your TEACH Profile to find the dates of your Registration Period): Begin Date: _________________ End Date: _________________________

Title of Program
	Approved CTLE Sponsor Name
	Sponsor Category*
	Dates (mm/dd/yyyy)
	Location
	Content / Pedagogy / Language Acquisition
	Clock Hours

							

							

							

							

*Sponsor Categories: 1 = Public School; 2 = BOCES; 3 = Teacher Center; 4 = College/University; 5 = “Other NYSED-Approved Sponsor” DO NOT SUBMIT THIS FORM. PLEASE KEEP FOR YOUR OWN RECORDS.
Office of Teaching Initiatives Web site: www.highered.nysed.gov/tcert/     E-Mail: CTLE@nysed.gov