TRAINING PROVIDER
Application for Initial Approval
New Jersey Department of Labor and Workforce Development
Training Evaluation Unit
PO Box 057
Trenton, NJ 08625-0057
ALL FORMS MAY BE DUPLICATED AS NEEDED
(R-5-13)
1
REQUIREMENTS FOR TRAINING PROVIDER APPROVAL
(You must provide one (1) application for each training site.)
Organization Name:
Date Initial Application Submitted ___/___/_____
The following documents must be submitted to receive Training Provider approval. Please check (√) items to ensure inclusion.
Included
(√)
Item
1.
Completed Program/Provider Information Form
2.
Proof of non-profit registration 501(c)(3), charitable registration number,
religious operation/control, labor organization, or public/governmental agency.
3.
Three (3) letters of reference for the school’s owner(s), administrator(s) and
director(s), attesting to their reputation for integrity and good business practices.
4.
Certificate of Occupancy from your local municipality for the Site of Instruction
5.
Copy of signed rental agreement/lease or proof of ownership for Site of
Instruction
6.
Certificate of Fire Inspection for the Site of Instruction (current)
7.
Certificate of Health Inspection (current, if applicable)
8.
Certificate of Public Liability and Workers Compensation for Site of Instruction
9.
Certificate of Authority or Corporate Registration
For LWD Use Only (√)
Needs Further
Acceptable
Development
10. Business Registration Certificate, issued by the NJ Div. of Revenue, for the
organization listed on page 3 (Program/Provider Information) of this application.
11. Sketch of floor plan showing exits, restrooms, break-rooms, classrooms, etc.
12. Complete curriculum (refer to NJAC 12:41 and the enclosed Curriculum
Assessment Checklist or Literacy Curriculum Checklist).
13. Certificate or letter from a local/national agency evaluating curriculum program
content; evidence that the curriculum is aligned to a national or industry standard;
or three (3) letters attesting to Advisory Board reviews.
14. Copies of other agency approvals for courses/programs (i.e., Board of Nursing
for Certified Home Health Aide or Licensed Practical Nurse; Department of
Health and Senior Services for Certified Nurse Aide).
15. Documentation of recordkeeping process.
16. Student Handbook, which includes the following statement on its front cover,
“Only individuals referred by the One-Stop Career Center and its Partners can
attend/enroll in the Training Provider Programs.”
17. Instructor qualifications including appropriate industry credentials.
18. Completed Section J for each program (include CIP Code, tuition and fees).
19. Signed and notarized Statement of Assurances
20. Are these programs offered in response to a Request for Proposal (RFP)?
ALL FORMS MAY BE DUPLICATED AS NEEDED
(R-5-13)
Yes ‰ No ‰
If Yes, provide a copy of RFP
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PROGRAM/PROVIDER INFORMATION
‰ Non-profit/501(c)(3) tax exempt status
‰ Charitable (Registration #: ______________________________________________)
‰ Public/governmental agency
‰ Labor Organization
‰ Faith-based
‰ Other (please specify): _____________________________________________
Organization Name:
Address:
Phone:
FAX:
Email Address:
Federal ID #:
Principal Owner(s)/Administrator(s) Name(s):
‰ Yes
Corporation:
‰ No
‰ Yes
Partnership:
‰ No
Has an owner/administrator been involved in the operation of an approved program at any other location or in another state?
‰ Yes ‰ No
If yes, please provide location and date:
Is this organization currently approved to provide training through any other approval process or by any other state agency?
‰ Yes ‰ No
If yes, please provide copies of other approvals.
Owner’s/Administrator’s Signature:
LOCAL AREA INFORMATION
Contact’s Name:
Email Address:
SITE OF INSTRUCTION (Must provide one (1) application per training site.)
Site Name:
Address:
Phone:
FAX:
Email Address:
Name of Director (person physically present at each program site):
Name of Co-Director (person in-charge when Director is not present):
Program Title(s):
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
ALL FORMS MAY BE DUPLICATED AS NEEDED
(R-5-13)
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CURRICULUM ASSESSMENT CHECKLIST
Organization Name:
Program Name:
Instructions: This checklist is required to assess each curriculum proposal and to ensure all the necessary curriculum components
have been developed. Each curriculum proposal must include the item identified below. The General Information and Curriculum
Outline/Instructional Strategies forms must be submitted along with this checklist.
Included
(√)
Item
1.
Program Title: Provide the title of the program to reflect the training the student
will receive, as listed on page 3 of this application.
2.
Program Description: Provide a brief description of what the program is about,
for whom it is intended and its purpose.
3.
Competencies: Describe the occupational objectives and competencies to which
the program is aligned. Provide the nationally recognized curriculum or industry
standard to which the program is aligned.
4.
Prerequisites for Enrollment: Provide a list of prerequisites for this program,
including skills required and courses required to be completed prior to
enrollment. Include competencies students need to meet prior to enrolling in the
program.
5.
Instructional Hours: Provide, in outline form, the topics/subjects that will be
covered. Include the number of hours for each topic/subject, program length and
the total number of instructional hours (not including lunch breaks) for the
program.
6.
Instructional Staff: Provide résumés along with appropriate job titles of
instructional staff. If staff has not been identified, provide a description of the
qualifications and required certification, where applicable.
7.
Outline of Subjects/Complete Curriculum: Describe the major elements of
instruction of the program. Provide the necessary curriculum components,
including subjects or topics, of each course within the program.
8.
Instructional Strategies: Describe the intended instructional methods to be
used, audio/visual aids and other educational technology planned.
9.
Equipment and Supplies: List the equipment, tools and text materials that will
be used in the program to fulfill the identified competencies and skills.
For LWD Use Only (√)
Needs Further
Acceptable
Development
10. Evaluation: Describe the method(s) by which students will be evaluated
including, where applicable, the national or state licensing/certification test.
Include the grading policy and a copy of a vocational/technical skill proficiency
assessment instrument. Provide specific techniques you will use to measure
students’ progress and evaluations for each major element of instruction (tests,
quizzes and all internships) and supply samples of each.
11. Enrollment: Estimate the maximum number of students you expect to enroll in
each program’s classroom.
12. Section J: Complete one (1) Section J for each program. Include program title
(as listed on page 3 of this application), CIP Code, tuition, fees and program
description as it will appear on the Eligible Training Provider List (ETPL).
For Department of Labor and Workforce Development Use Only
Education Program Development Specialist
ALL FORMS MAY BE DUPLICATED AS NEEDED
(R-5-13)
Date
4
LITERACY CURRICULUM ASSESSMENT CHECKLIST
Organization Name:
Program Name:
Instructions: This checklist is required to assess each literacy curriculum proposal and to ensure all the necessary curriculum components have
been developed. Each curriculum proposal must include the item identified below. The General Information and Curriculum Outline/Instructional
Strategies forms must be submitted along with this checklist.
For LWD Use Only (√)
Included
(√)
Item
Acceptable
Y
1.
Specific targeted population.
2.
Program Title: Provide the title of the program to reflect the training the student will receive, as
listed on page 3 of this application.
3.
Curriculum Description/Outline of Subjects: Each curriculum must:
ƒ
Provide in narrative form a program description including the major elements of instruction;
ƒ
Provide the necessary curriculum components, including subjects or topics for each course
within a program;
ƒ
Provide Core Literacy Curriculum which should include instructional practices, such as but
not limited to: phonemic awareness, systemic phonics, fluency, and reading comprehension;
ƒ
Learning should be in real-life contexts to ensure that individuals gain the skills necessary to
compete in the workplace; and,
ƒ
Activities should be built on a strong foundation of research and effective educational
practices.
4.
Competencies: Describe the literacy objectives and competencies to which the program is
aligned. Provide the nationally recognized curriculum standard to which the program is aligned.
5.
Prerequisites for Enrollment: Provide a list of prerequisites for this program, including skills
required and courses required to be completed prior to enrollment. Include competencies students
need to meet prior to enrolling in the program.
6.
Instructional Hours: Classes of sufficient intensity and duration to enable the student substantial
learning gains. Provide, in outline form, the topics/subjects that will be covered. Include the
number of hours for each topic/subject, program length and the total number of instructional
hours (not including lunch breaks) for the program.
7.
Instructional Strategies: Describe the intended instructional methods to be used, audio/visual
aids and other educational technology planned.
8.
Equipment and Supplies: List the equipment, tools and text materials that will be used in the
program to fulfill the identified competencies and skills.
9.
Evaluation: Describe the method(s) by which students will be evaluated including, where
applicable, the national or state licensing/certification test. Include the grading policy and a copy
of a vocational/technical skill proficiency assessment instrument. Provide specific techniques you
will use to measure students’ progress and evaluations for each major element of instruction
(tests, quizzes and all internships) and supply samples of each.
N
Comments/
Specific
Deficiency
10. Instructional Staff: Provide résumés along with appropriate job titles of instructional staff. If
staff has not been identified, provide a description of the qualifications and required certification,
where applicable.
11. Enrollment: Estimate the maximum number of students you expect to enroll in each program.
12. Section J: Complete one (1) Section J for each program. Include program title (as listed on
page 3 of this application), CIP Code, tuition, fees and program description as it will appear on
the Eligible Training Provider List (ETPL).
For Department of Labor and Workforce Development Use Only
Education Program Development Specialist
ALL FORMS MAY BE DUPLICATED AS NEEDED
(R-5-13)
Date
5
GENERAL INFORMATION
(Complete for each program submitted for approval)
Organization’s Name:
Program Title (as listed on page 3 of this application):
Program Length (in hours):
Program Days/Hours:
Class Size:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Pre-Assessment & General Program Prerequisites (minimum level requirements) - Example: TABE Test, etc.:
Program Description (describe in detail, be specific):
Program Goals (What knowledge or ability will the student obtain, upon successful completion, as a result of this program?):
ALL FORMS MAY BE DUPLICATED AS NEEDED
(R-5-13)
6
CURRICULUM OUTLINE/INSTRUCTIONAL STRATEGIES
Organization’s Name:
Program Title (as listed on page 3 of this application):
Intended Instructor’s Name:
•
•
•
•
•
COMPETENCY: List sequentially the units of instruction including measurable competencies.
CUMMULATIVE HOURS: Specify the instructional hours and/or weeks assigned to each competency.
INSTRUCTIONAL METHODS: List the method of instruction to be used for each competency.
BOOKS, MATERIALS, EQUIPMENT: Describe the specific materials to be used including titles and/or
publishers. Include samples of teacher-developed materials and copies of published Table of Contents,
along with copyright information.
EVALUATION: List the methods of evaluation used for each competency. Include samples of tests,
quizzes, etc.
COMPETENCY
(COURSE)
List specific content
goals of the course.
CUMMULATIVE
HOURS
ALL FORMS MAY BE DUPLICATED AS NEEDED
(R-5-13)
INSTRUCTIONAL
METHODS
BOOKS,
MATERIALS,
EQUIPMENT
EVALUATION
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NEW JERSEY DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
TRAINING PROVIDER
SECTION J
Instructions: New schools must list all programs that will be offered and attach a copy of the curriculum for each program. Existing schools must complete Section J forms for new and modified
programs and submit a copy of the curriculum for new and modified programs only. All program curricula must be aligned with National or Industry Skill Standards or an Advisory Board. Submit a
copy of the standard to which each new/modified curriculum is aligned or three (3) Advisory Board letters. Provide the CIP Code for each program title. CIP Codes can be found at
http://nces.ed.gov/ipeds/cipcode/crosswalk.aspx?y=55. Please provide the program description as it will be entered on the Eligible Training Provider List (ETPL).
USE A SEPARATE SECTION J FOR EACH PROGRAM. PLEASE COPY THIS FORM AS NEEDED. THIS FORM MAY NOT BE MODIFIED.
Organization Name:
Telephone Number:
Director’s Name:
Status:
New/
Modified/
Current*
Program Title
(as listed on page 3 of this application)
Address:
FAX Number:
County:
Industry
Partnership
Number
Email Address:
Federal ID Number:
CIP
Code
Hours of
Instruction
Tuition
Admin.
Fees
Text
Book
Fees
Tool/
Supply
Fees
Test/
Licensing/
Inoculation
Fees
Other
Total
PROGRAM DESCRIPTION: For each new or modified program with changes to curriculum or change in CIP code, please provide the program description as it will be entered
on the Eligible Training Provider List (ETPL). Limit the description to no more than 250 words. Attach additional sheets if more space is needed.
*Explain all modifications and entries in the “Other” column:
REVIEWED BY:
Program Specialist
NJ Department of Labor & Workforce Development
ALL FORMS MAY BE DUPLICATED AS NEEDED
(R-5-131)
Date
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STATEMENT OF ASSURANCES
By the signature which appears below, the Training Provider making this application certifies the following:
•
•
•
This organization is not currently suspended, debarred or revoked from providing services to any public
entity including the State of New Jersey.
Fire, health inspection and liability certificates are current and on file at the school and will be made
available at the request of a representative of the New Jersey Department of Labor and Workforce
Development.
The applicant assures that it will comply fully with the nondiscrimination and equal opportunity provisions
of the following laws:
o
o
o
o
o
o
Section 188 of the Workforce Investment Act;
Title VI of the Civil Rights Act of 1964;
Section 504 of the Rehabilitation Act of 1973;
Age Discrimination Act of 1975;
Title IX of the Education Amendments of 1972; and,
Americans with Disabilities Act, 42 U.S.C 12102
In addition, the applicant also assures that it will comply with the U.S. Department of Labor’s regulations
at 29 CFR, Part 37 and all other regulations implementing the laws listed above.
I hereby give assurance that the statements above are true and correct.
Organization Name:
Address:
Administrator’s Name:
Administrator’s Signature:
Date:
AFFIDAVIT
State of New Jersey, County of
,
(Name), being duly sworn on his/her oath that
he/she is
(Title) of the
(School), in the County of
and that the Statements given in this application are true,
to the best of his/her knowledge and belief.
School Administrator’s Signature
Sworn and subscribed to before me this
day of
, 20
.
Notary Public’s Signature and Seal
ALL FORMS MAY BE DUPLICATED AS NEEDED
(R-1-11)
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