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Jumat, 25 September 2020

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Dear Student,
Pursuant to the Abraham S. Fischler College of Education (FCE) Student Grievance
Procedure, the Grievance Form is for use in filing a grievance when a satisfactory
resolution is not achieved through a formal appeal. Please note that this form and any
supporting documentation must be properly completed, received, and on file in the
Office of Student Judicial Affairs (OSJA) within fifteen (15) days following receipt of
correspondence disclosing the appeal committee's decision, otherwise, the grievance
will no longer be eligible for review. Students are encouraged to submit the Grievance
Form, and any supporting documentation, well in advance of the fifteen (15) day
deadline for submission.
Should you have any questions or need assistance with the completion and/or
submission of a grievance, please contact OSJA at 9980933775 (toll free at 972256
2210, ext. 13064)
Sincerely,
Office of Student Judicial Affairs
Abraham S. Fischler College of Education

----GqPGioMI;vesooy Dear Education Applicant: Thank you for your interest in applying to the Indian Hills Community College Education program. Our program prepares the student to become a classroom teacher in a public or private school district anywhere from Preschool to 12 th grade. By entering the Education program, the student is on a path to gain teacher licensure in the state of Iowa or any other state. According to the Iowa Board of Educational Examiners (BOEE), a state background check and a national fingerprint background check and a check of the sex offender and child and dependent adult abuse registries is to be conducted on all applicants preparing to obtain an Iowa teaching licensure (2019). Therefore, this program is closed to all applicants with a felony record, conviction of a serious misdemeanor crime or any crime of immorality. Background checks are required pending entrance to the Education program since it would be unfair to the student for Indian Hills Community College to allow a student to complete the entire education curriculum only to be refused acceptance into a 4-year institution, licensure and or employment. There are two documents to complete. One is a Questionnaire for Participation Form and the other is the Criminal History Record Check Authorization for Release Form. The Questionnaire for Participation Form is required to be in compliance with Iowa law which is states that this institution can only receive a criminal background check for violations and convictions in the State of Iowa. In completing and signing this form, you, the applicant states that you have not been charged with or convicted of the above listed offenses anywhere in the United States. Again, it would be unfair for an applicant to successfully complete the education program only to be turned away from a 4-year institution or unemployable in the field. Along with the two forms, a check, money order or cashiers check payable to Indian Hills Community College in the amount of $20.00 is required as a processing fee and should be placed in the same envelope with the two forms. Upon receipt of the completed forms and money, we will submit the Criminal History Record Check Authorization for Release Form to the Iowa Department of Criminal Investigations (DCI) to perform the background check. A reply is usually received with a day or two. At that point you will be allowed into the program. It is very important to complete the forms and send the processing fee as soon as possible to be accepted into the Education program prior to the start of Fall term. Your documentation will not be processed without both forms or the money to process the forms. Again, please complete both forms and add a check, money order or cashier's check and mail to: ATTN: Program Director, Education Indian Hills Community College 525 Grandview Ave Ottumwa, IA 52501 We appreciate your interest in the Indian Hills Community College Education program and sincerely look forward to working with you. If you have any questions feel free to contact me at (641) 683-5111, ext. 1835 or by email at Debra.Vos@indianhills.edu Respectfully, Deb Vos Ed. S Program Director, Education QUESTIONNAIRE FOR PARTICIPATION IN THE INDIAN HILLS COMMUNITY COLLEGE EDUCATION PROGRAM YOUR POLICE RECORD For this item, report information regardless of whether the record in your case has been "sealed" or otherwise stricken from the court record. The single exception to this requirement is for certain convictions under the Federal Controlled Substances Act for which the court issued an expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. Yes NO 1. Have you ever been charged or convicted of any felony offense (Including those under the Uniform Code of Military Justice) ___ ___ 2. Have you ever been charged with or convicted of a firearms or explosives offense? ___ ___ 3. Have you ever been charged with, convicted of or is there currently any charges pending against you for domestic abuse? ___ ___ 4. Have you ever been charged with or convicted of any offense(s) related to alcohol or drugs? ___ ___ 5. In the last 5 years, have you been arrested for, charged with, or convicted of any offense(s) not listed to questions 1-4 above? (leave out traffic fines of less than $150 unless the violation was alcohol or drug related.) ___ ___ _________________________ Print Your Full Name _________________________ ___________ Signature Date __________________________________________ _______________ Address City Phone Declaration – I declare that the information that I have given is correct, and I understand that any attempt to give false information could lead to removal from the class and the Education Program. STATE OF IOWA Criminal History Record Check Request Form DCI Account Number: (if applicable) To: Iowa Division of Criminal Investigation From: Support Operations Bureau, 1st Floor 215 E. 7th Street Des Moines, Iowa 50319 (515) 725-6066 (515) 725-6080 Fax Phone: Fax: I am requesting an Iowa Criminal History Record Check on: Iowa Criminal History Record Check Results (DCI use only) As of , a search of the provided name and date of birth revealed:  No Iowa Criminal History Record found with DCI  Iowa Criminal History Record attached, DCI # DCI initials Last Name (mandatory) First Name (mandatory) Middle Name (recommended) Date of Birth (mandatory) Gender (mandatory) Social Security Number (recommended) Male Female Waiver Information: Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always obtain a waiver signature from the subject of the request. Waiver Release: I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the Division of Criminal Investigation (DCI). Any criminal history data concerning me that is maintained by the DCI may be released as allowed by law. Waiver Signature: ----jy28J0Iu;nTrnpn


Cardinal Station Newburg Center for Primary Care
215 Central Avenue, Suite 100 1941 Bishop Lane, Suite 900 215 Central Avenue, Suite 205
Louisville, KY 40208 Louisville, KY 40218 Louisville, Ky 40208
I:\FCM\Phyllis Harris\Forms\New Patient Pkg Components
UofL Department of Family & Geriatric Medicine
Dear New Patient,
Welcome to your University of Louisville Physicians Family practice! We
are offering patient-centered medical care and are enthusiastic about our
relationships with our patients. In order to better serve your needs, we are
enclosing several forms and ask that you completely fill each form out.
The first sheet will help us learn more about you; please completely fill out this
form about your family history. The next sheet is titled, "Authorization for the
use and/or Disclosure of Protected Health Information", and you will need to
completely fill that out for our doctors to treat you to the best of their ability; it
gives us permission to review your medical records from your previous primary
medical facilities.
Following, please completely fill out the Registration, Social Services & Consent
Form. Next, you will find our Privacy Notice, followed by an acknowledgement that
you have received and understand our Privacy Policies. Finally, the last form is the
Office Acknowledgements and Policies form. Please read carefully and sign
your name at the bottom of the letter.
Please make sure to bring all of these forms with you to your first office visit.
Do not mail them back to the office. Also, please remember to always
bring your picture ID, current insurance cards and your co-payment. If your
health insurance requires you to select a primary care doctor please do so prior to
your office visit. Please bring in any and all medication you take, in their
original bottles, to your appointment.
If the patient is under 18 years of age he or she must be accompanied by an
adult and will need to bring a copy of their current immunization certificate.
Please arrive 15 minutes ahead of your scheduled appointment time so that if
you have questions about these forms or we need more information, we can
address it all prior to your appointment.
We look forward to seeing you!
University of Louisville Physicians
UofL Family and Geriatric Medicine

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Dear Prospective Ed.D., Higher Education Strand Applicant:
We are very pleased that you are interested in the Higher Education Strand of CCSU's Doctor of
Education (Ed.D.) in Educational Leadership, designed for current higher education professionals
who aspire to leadership positions on college or university campuses. We look forward to receiving
your application.
As you complete your application, keep in mind the following admission criteria:
1. Master's degree from an accredited institution of higher education in a discipline or
professional field that is relevant to the Ed.D. in Educational Leadership.
2. A 3.00 or higher cumulative average (GPA) in all graduate coursework.
3. Two or more letters of reference from leaders in postsecondary education familiar with
your work. Ask your references to use the form on the next page.
4. Résumé that illustrates important work-related experiences with an emphasis on yo ur
work as a leader at postsecondary institutions of higher education.
5. Acceptable scores on the General Test of the Graduate Record Examination (GRE) taken
within five years of your application.
6. A personal statement covering six important topics:
• Career goals
• Intended area of individual specialization
• Reasons for pursuing a doctorate
• Commitment to residency requirements (one three-day weekend in the first spring
semester, one full week each of the first, second, and third summer sessions)
• Commitment to enrolling in two cohort courses each spring and fall semester
• Commitment to summer enrollment during each 8-week summer session
7. If selected as a finalist, a satisfactory interview with the admissions committee.
We accept new students in alternate years only. Applications are due by October 1, 2017.
Admission standards are rigorous, and not everyone who meets our standards wil l be accepted.
Please note that the admission process calls for submission of materials to two locations. The last
page of this packet is a checklist of the various steps. Submit your Graduate Application and $50
application fee online. Transcripts from every college you have attended as an undergraduate and
graduate student should be submitted to Graduate Admissions in 102 Barnard Hall. In addition you
must send the following materials directly to the Ed.D. Program (attention Rouzan Kheranian) in 320
Barnard Hall:
1. Two letters of recommendation from educational leaders. Use the Reference Form (page
2 of this packet).
2. Your personal statement attached to the form on page 3 of this packet.
3. Your résumé.
4. Your GRE scores. When requesting that scores be sent, use GRE reporting code 3143 to
assure that the Ed.D. office receives your scores.
Cordially,
Peter F. Troiano, Ph.D.
Ed.D. Program Direct or, Higher Education Strand

----evytCpDN;uwZoor Dear colleague, thank you for your interest in the Language A – School-supported Self-taught Literature one-day workshop to be held on Monday June 10th at the ESF Centre in Hong Kong. This workshop will provide a unique opportunity for coordinators, supervisors and teachers to immerse themselves in the format, the features, the requirements and the assessments of this course (first exams in 2021). We will look in depth at the SS part and at the ST part of the course. This workshop also aims to provide every school and every participant with a clear understanding of the SSST course and of the changes that are taking place in the Group 1 courses this year. You will be delighted to find out, for instance, that some of the features of the existing SSST course will now spill over into the taught courses also … but more on this on June 10th ! The SSST course is an integral feature of the Diploma Program of every IB school as it provides every student, no matter their cultural and linguistic background, with the opportunity to study literature in and through their mother tongue / first language / strongest language. I commend your school for either already running this course, or for considering implementing it in the near future. In order to complete your registration for the workshop, please do the following : 1. answer the short questionnaire that you find at the bottom of this message; 2. make payment using the details provided below; 3. send a scanned copy (or a picture) of the payment/deposit slip to my email address. Please be reminded that the deadline for registration is June 5th. In order to assist us with the planning for the event, feel free to register at your earliest convenience. The provisional schedule for the day is attached below. I look forward to a wonderful day of sharing, learning and inspiring, and I thank you once more for your interest. Please do not hesitate to get in touch if you have any questions prior to the event. Best wishes, Ronny Mintjens rmintjens@gmail.com Page 2 Language A SSST workshop Hong Kong – June 2019 Payment details The participation fee is HK$ 800 per participant. Payment can be made by bank deposit / transfer or by cheque. Please contact me for bank details / address details. rmintjens@gmail.com Please ensure that your payment has been completed by June 5th at the latest. (Registration deadline is June 5th, 2019) Page 3 Language A SSST workshop Hong Kong – June 2019 Participant information (please fill out and send this table back by email) Name Email address School Your role in the SSST course Years of SSST experience Average number of SSST students per year SSST language(s) administered in your school this year Burning question(s) that you would like to see us address during the workshop Page 4 SEMINAR ON THE NEW LANGUAGE A LITERATURE SCHOOL-SUPPORTED SELF-TAUGHT COURSE ESF Centre, North Point Hong Kong, June 10th 2019 Presenter Ronny Mintjens is a qualified language teacher from the University of Antwerp (Belgium). He started teaching IB French at the United World College of Southern Africa in Swaziland in 1989 and moved to an IB school in Tanzania in 1995 where he taught French, Spanish and German. He subsequently taught part-time French and Spanish in Qatar (in between his football coaching work with the National Under-14 team), and became Head of Languages at the Li Po Chun United World College of Hong Kong in 2006. He currently teaches French, Spanish and English and he also coordinates the college's vast Language A School-Supported Self-Taught (Mother Tongue) program. Ronny is a member of the IB's SchoolSupported Self-Taught Curriculum Steering and Review Committee, and he also serves as the IB Programme Communities Moderator for Language A "Other Languages" and "School-Supported SelfTaught". He is also an experienced workshop leader, a workshop developer, an IB School Visit Team Member and a Language Ab Initio examiner. 2019 marks his 30th year as an IB teacher. At the time of writing (April 2019) Ronny is the only IB workshop leader on the planet to have conducted a full three-day Subject-Specific Seminar for the new Literature A – School-Supported Self-Taught course (in Bangkok, March 2019). During his many years of implementing, administering, planning, supervising and teaching the SSST course, Ronny has learned that nothing beats the enjoyment gotten from observing students being creative with and exploring top class literature in their mother tongue as well as through translation. Ronny is a regular speaker on the IB circuit as well as in professional and social gatherings. He has been a Head of Department for the past 19 years. He is the author of an auto-biographical novel based on his 15 years in African football ("More than a Game") and of a photographic album that takes the reader on a visual journey through North Korea, a country where he has been setting up educational goodwill initiatives and lecturing at a local university ("A Journey through North Korea"). In the past two years Ronny has published a number of Language Ab Initio-specific resources, including the very popular "Language Ab Initio Student Workbook" and the "Language Ab Initio Portfolio" series for French, Spanish, Mandarin and English. In addition, he has published similar Language B and Language MYP resources. The objective for this workshop is that by the end of the day the participants will walk away with an indepth and practical understanding of the changes that are about to take place in the Literature A SSST course (first exams in 2021) and of the expectations and assessments in the new course. Page 5 SEMINAR ON THE NEW LANGUAGE A LITERATURE SCHOOL-SUPPORTED SELF-TAUGHT COURSE 08.00 - 08.30 Registration and refreshments 08.30 - 10.00 Session 1 Introductions Introducing the new SSST course Old vs New – requirements Overview of the main changes in course structure and assessment The roles of the SSST supervisor 10.00 – 10.30 Morning break 10.30 - 12.30 Session 2 Constructing a program of study Profiling the student The areas of exploration (AoE) The Prescribed Reading List (PRL) Practical exercise : Designing a course for student X and working towards the assessments 12.30 - 13.30 Lunch 13.30 - 15.00 Session 3 The Learner Portfolio Format, logistics and management The assessments Paper 1 Paper 2 Individual Oral (SSST variant) 15.00 – 15.30 Afternoon break Page 6 15.30 – 16.00 Session 4 Sharing our ways forward Q&A Conclusions All participants are requested to bring the following : • Laptop (please ensure that your school has given you sufficient administrator rights to be able to change your IP/network settings so that you can connect to the local network onsite) – bring a power adaptor • A USB thumb drive to share resources if you are not confident with googledocs or Dropbox • A soft or paper copy of the Language A Literature guide (first exams 2021) and the Language A School-Supported Self-Taught Student guide (first exams 2021) (both resources can be downloaded from the IB Programme Communities on MyIB) Please be advised that lunch is not included in the seminar fee.
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