Free 49484.FH11 - Indiana

RECORD OF LICENSE CODING - RULES 2002
State Form 49484 (R4 / 9-07)

Reset Form

* This agency is requesting disclosure of your Social Security number in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

RECORD OF LICENSE CODING
Name Action Social Security number *

Original Addition BASIS Rules 2002 VOID LICENSE

Duplicate Renewal 1 2 3 4 5 6

Conversion (Accomplished / Ten Year) Transition to Teaching (Original) DEGREE None Associate Bachelor Master Specialist Doctorate Praxis 1 Reading Writing Math Praxis 2 Reading Specialty

Extension TEST VERIFICATION Cut-off 176 172 175 Code 370 Score

Score

COLLEGE

INTERNSHIP PROGRAM IR / AR - Required IC / AC - Completed IN / AN - Not required

School Leaders Licensure Assessment

Gradation 10 Initial Practitioner 11 Proficient Practitioner 12 Accomplished Practitioner Content Areas
EC ELI EC ELI EC ELI EC ELI EC ELI EC ELI
Comments

158 165 (as of January 2005) Preparation Level 22 Administration 23 Workplace Specialist

13 Workplace Specialist 14 Reciprocal Permit

20 Instructional 21 School Services School Setting

Preschool / Early Childhood Elementary Intermediate Preschool / Early Childhood Elementary Intermediate Preschool / Early Childhood Elementary Intermediate Preschool / Early Childhood Elementary Intermediate Preschool / Early Childhood Elementary Intermediate Preschool / Early Childhood Elementary Intermediate

MS/JR Middle School / Junior High HS ALS HS ALS HS ALS HS ALS HS ALS HS ALS High School All School High School All School High School All School High School All School High School All School High School All School

ELP Elementary Primary

MS/JR Middle School / Junior High

ELP Elementary Primary

MS/JR Middle School / Junior High

ELP Elementary Primary

MS/JR Middle School / Junior High

ELP Elementary Primary

MS/JR Middle School / Junior High

ELP Elementary Primary

MS/JR Middle School / Junior High

ELP Elementary Primary

I certify that I have seen a valid certificate from an approved provider verifying that the applicant has completed training in adult / child cardiopulmonary resuscitation that includes a test demonstration on a mannequin and removing a foreign body causing an obstruction in an airway through the Heimlich maneuver.
Signature of Licensing Advisor Name of Institution Date signed (month, day, year)