Connecticut Ed 177 Form PDF Details

In order to receive your Connecticut education, you will need to complete the Ed 177 form. This form is used to determine your eligibility for the program and to provide information about your educational history. The Ed 177 form is also used to determine your funding eligibility. Make sure you complete the form accurately and honestly, so that you can receive the best possible education through the Connecticut program.

QuestionAnswer
Form NameConnecticut Ed 177 Form
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namesarea dsap form search, application dsap, application durational shortage dsap, ed177

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INSTRUCTIONS – PAGE 1

ED 177

CONNECTICUT STATE DEPARTMENT OF EDUCATION

REV. 9/20

Bureau of Educator Standards and Certification

C.G.S. 10-145

P.O. Box 150471

C.G.S. 10-145d

Hartford, CT 06115-0471

Regs. 10-145d-421, 422

 

 

www.ct.gov/sde/cert

 

INSTRUCTIONS FOR FORM ED 177

APPLICATION FOR FIRST ISSUANCE OF THE DURATIONAL SHORTAGE AREA PERMIT (DSAP)

A Durational Shortage Area Permit (DSAP) may be requested by the school or district if a position cannot be filled by an appropriately certified candidate. An application for issuance of a DSAP cannot be initiated by the applicant. The effective date of the DSAP may be the date the original ED 177 is received, provided all requirements for issuance have been met on or before this date. An

ED 177 must be submitted prior to the first day of employment.

Please complete the appropriate section of the checklist below.

CANDIDATE

a. Complete Parts I, II, and III of the application form (ED 177).

b. Attach official transcripts showing the completion of at least 12 semester hours of credit in the subject for which the DSAP is requested. An official transcript showing the completion of a bachelor’s degree must be included if the candidate has never held certification in Connecticut.

SCHOOL OR DISTRICT OFFICIAL

The application form (ED 177) and supporting documentation must be submitted by the employing agent to the Bureau of Educator Standards and Certification. The “Evidence of Enrollment” form ED 177 (Attachment) may be submitted separately.

a. Complete Parts IV and V of the application form (ED 177).

b. Complete the “Evidence of Enrollment” form ED 177 (Attachment) Part A, if applicable. If this part is required, return the

Attachment to the candidate for signature by the appropriate higher education official where the candidate is enrolling in a teacher preparation program or the Alternate Route to Certification program. The Attachment need not be completed if the candidate holds a valid Connecticut certificate and is completing course work under a DSAP to fulfill requirements for a cross endorsement (except for endorsements 102, 112 or 113), or if the candidate has at least 20 school months of successful appropriate* teaching experience in an approved nonpublic school.

EDUCATOR PREPARATION PROVIDER

a. Complete the “Evidence of Enrollment” form ED 177 (Attachment) Part B and Part C, if applicable. The Attachment need not be completed if the candidate holds a valid Connecticut educator certificate and is completing course work under a DSAP to fulfill requirements for a cross endorsement (except for endorsements 102, 112 or 113), or if the candidate has at least 20 school months of successful appropriate* teaching experience in the same approved nonpublic school.

*The twenty months must be in the subject area or field for which the initial educator certificate will be sought (CT State Regulation 10-145d-412 (3)(A)).

 

INSTRUCTIONS – PAGE 2

ED 177

CONNECTICUT STATE DEPARTMENT OF EDUCATION

REV. 9/20

Bureau of Educator Standards and Certification

C.G.S. 10-145

P.O. Box 150471

C.G.S. 10-145d

Hartford, CT 06115-0471

Regs. 10-145d-421, 422

 

 

www.ct.gov/sde/cert

APPLICATION FOR REISSUANCE OF THE DURATIONAL SHORTAGE AREA PERMIT (DSAP)

A Durational Shortage Area Permit (DSAP) may be requested by the employing agent of a board of education if a position cannot be filled by an appropriately certified candidate. An application for issuance of a DSAP cannot be initiated by the applicant. The effective date of the DSAP will be the date the original ED 177 is received, provided all requirements for issuance have been met on or before this date. An ED 177 must be submitted prior to the first day of employment.

The following checklist outlines the sections of the form to be completed and documents which must be submitted by the employing agent in order for the Bureau of Educator Standards and Certification to determine eligibility for a DSAP.

CANDIDATE

a. Complete Parts I, II, and III of the application form (ED 177).

b. Attach official transcripts showing the completion of at least nine semester hours of credit during the validity period of the previous DSAP in the subject for which the DSAP is requested.

SCHOOL OR DISTRICT OFFICIAL

The application form (ED 177) and supporting documentation must be submitted by the employing agent to the Bureau of Educator Standards and Certification. The Attachment may be submitted separately.

a. Complete Parts VI and VII of the application form (ED 177).

b. Complete the “Evidence of Enrollment” form ED 177 (Attachment) Part A, if applicable. If this part is required, return the

Attachment to the candidate for signature by the appropriate higher education official where the candidate is enrolling in a teacher preparation program or the Alternate Route to Certification program. The Attachment need not be completed if the candidate holds a valid Connecticut certificate and is completing course work under a DSAP to fulfill requirements for a cross endorsement (except for endorsements 102, 112 or 113), or if the candidate has at least 20 school months of successful appropriate* teaching experience in an approved nonpublic school.

EDUCATOR PREPARATION PROVIDER

a. Complete the “Evidence of Enrollment” form ED 177 (Attachment) Part B and Part C, if applicable. The Attachment need not be completed if the candidate holds a valid Connecticut educator certificate and is completing course work under a DSAP to fulfill requirements for a cross endorsement (except for endorsements 102, 112 or 113), or if the candidate has at least 20 school months of successful appropriate* teaching experience in the same approved nonpublic school.

*The twenty months must be in the subject area or field for which the initial educator certificate will be sought (CT State Regulation 10-145d-412 (3)(A)).

INSTRUCTIONS – PAGE 3

ED 177

CONNECTICUT ENDORSEMENT CODES

Teaching Endorsements

010Business, 7–12

015English, 7–12

018French, 7–12

019German, 7–12

020Italian, 7–12

021Latin, 7–12

022Russian, 7–12

023Spanish, 7–12

024Other World Language, 7–12

026History & Social Studies, 7–12

029Mathematics, 7–12

030Biology, 7–12

031Chemistry, 7–12

032Physics, 7–12

033Earth Science, 7–12

034General Science, 7–12

035Driver Education

040Agriculture, Pre-K–12

041Vocational Agriculture, 7–12

042Art, PK–12

043Health, P –12

044Physical Education, PK–12

045Home Economics, PK–12

047Technology Education, PK–12

049Music, PK–12

055Partially Sighted, PK–12

057Deaf and Hard of Hearing, PK–12

059Blind, PK–12

062School Library Media Specialist

072 School Nurse-Teacher

073School Dental Hygienist-Teacher

089Marketing Education, 7–12

101World Language Instructor, Elementary

102Remedial Reading & Remedial Language Arts, 1–12

104Cooperative Work Education/Diversified Occupations

110Unique Subject Area

111Teaching English to Speakers of Other Languages (TESOL), PK–12

112Integrated Early Childhood/Special Ed., Birth – Kindergarten

113Integrated Early Childhood/Special Ed., Nursery -K–Elem. 1–3

165Comprehensive Special Education, K–12

215English, Middle School

226History & Social Studies, Middle School

229Mathematics, Middle School

230Biology, Middle School

231Chemistry, Middle School

232Physics, Middle School

233Earth Science, Middle School

234General Science, Middle School

235Integrated Science, Middle School

305Elementary, 1 – 6

317Portuguese, 7–12

318Mandarin Chinese, 7–12

483Dance, Pre-K–12

485Theatre and Drama, Pre-K–12

511Montesori, Elementary, 1–6

512Montesori, Primary, Birth to Kindergarten

826Vocational Department Head: Trade Technology

Administrative Endorsements

Adult Education Endorsements

 

 

085

School Business Administrator

088

Non-English Speaking Adults

092

Intermediate Administration or Supervision

106

High School Credit Diploma Program

093

Superintendent of Schools

107

External Diploma Program/Noncredit Mandated Programs

097

Reading and Language Arts Consultant

 

 

105

Department Chairperson

 

 

 

 

 

Special Services Endorsements

 

 

061

Speech and Language Pathologist

Vocational Endorsements

068

School Counselor

082

Vocational Technical Administrator

070

School Psychologist

090

Occupational Subject, Vocational Technical Schools

071

School Social Worker

091

Trade-Related Subjects, Vocational Technical Schools

268

School Marriage and Family Therapist

098

Trade & Industrial Occupations – Comprehensive High School

 

 

103

Health Occupations – Comprehensive High School

 

 

108

Practical Nurse Education Instruction

NOTE: Bilingual codes are not provided. Check appropriate box on application to request a bilingual endorsement.

PAGE 4

ED 177

CONNECTICUT STATE DEPARTMENT OF EDUCATION

REV. 9/20

Bureau of Educator Standards and Certification

C.G.S. 10-145

P.O. Box 150471

C.G.S. 10-145d

Hartford, CT 06115-0471

Regs. 10-145d-421, 422

www.ct.gov/sde/cert

 

APPLICATION FOR DURATIONAL SHORTAGE AREA PERMIT (DSAP)

PART I: PERSONAL INFORMATION (Print all information in blue ink and in uppercase letters.)

LAST NAME

FIRST NAME

˗ ˗

SOCIAL SECURITY NUMBER

ADDRESS (Street ONLY, no P.O. Box)

CITY

˗

ZIP CODE

MIGENDER ˗ ˗

BIRTH DATE (Month-Day-Year) - Required

APT. #

(State)

FORMER LAST NAME(S)

PHONE

 

 

 

 

 

˗

 

 

 

 

 

˗

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Home/Cell)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race/Ethnicity

 

 

 

 

 

 

 

˗

 

 

 

 

 

˗

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Work)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Optional)

E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Have you ever been convicted of any crime, excluding minor traffic violations?

 

 

 

 

YES

 

 

 

 

2.

Have you been dismissed for cause from any position?

 

 

 

 

YES

 

 

 

 

 

 

 

 

3.

Have you ever surrendered a professional certificate, license, permit or other credential

 

 

 

YES

 

 

 

 

 

 

 

(including, but not limited to, an education credential); had one revoked, suspended,

 

 

 

 

 

 

 

annulled, invalidated, rejected or denied for cause; or been the subject of any other

 

 

 

 

 

 

 

adverse or disciplinary credential action?

 

 

 

 

 

 

1.Native American

2.Asian/Pacific Islander

3.Black

4.White

5.Hispanic

NO

NO

NO

Pursuant to Connecticut General Statutes Section 10-221d, the State Board of Education must submit, periodically, a database of applicants for an initial issuance of a certificate, authorization or permit to the State Police Bureau of Investigation for a criminal history record check. Each applicant seeking an initial issuance or renewal of a certificate, authorization or permit must also submit to a records check of the Department of Children and Families’ child abuse and neglect registry established pursuant to Connecticut General Statutes Section

17a-101k. In addition, the State Board of Education is required to submit periodically for criminal history records check the database of all persons who hold any certificate, authorization or permit.

NOTE: If you answer “YES” to any of the above questions, you must attach a signed statement of explanation. If there are multiple incidents within each question, you must list and explain each separately. Submit official copies of court or administrative record(s), including disposition of each case.

Original Signatures Must Be On The Form Submitted

PAGE 1

ED 177

PART II: EDUCATIONAL BACKGROUND

List the names of the colleges or universities attended:

 

 

Dates Attended

Major Field

Degree

Name of Institution

State/Country

From To

of Study

Awarded

 

 

 

 

 

 

 

 

 

 

PART III: CANDIDATE ATTESTATION

I certify that the information provided by me on this application and any accompanying documents contains no material misrepresentations, falsifications or omissions and that all of the information given by me is true, complete and accurate. I understand that all application and accompanying information may be verified and that any material misrepresentation, falsification or omission may result in the denial or revocation of my certificate(s), permit(s) or authorization(s).

By checking the “I Agree” box, you agree your typed signature is the legal equivalent of your manual signature on this application.

I Agree

SIGNATURE OF CANDIDATE:

DATE:

PART IV:

SCHOOL OR DISTRICT REQUEST FOR FIRST ISSUANCE OF THE DSAP

1.No certified candidate suitable for the position is available to serve in the subject(s) requested. I hereby request issuance of a DSAP for the applicant to serve as:

 

 

 

Endorsement Required for Position

Specific Subject or Field to be Taught

Grade Level

(see endorsement code list)

Check box if bilingual endorsement is sought in above subject.

Indicate language of the bilingual endorsement

2.List the steps that have been taken to secure a suitable certified person, including dates and specific locations of newspaper, media, vacancy notices, university postings, Internet job positions, teacher agency listings, etc. Please note that advertisements must be within 6 months.

a. Total number of candidates who applied for this position:

b. Number of candidates who hold appropriate Connecticut certification:

c. Number of candidates interviewed for this position:

d.Reason(s) why certified candidates, if any, were not hired. Include any circumstances and conditions which make this position difficult to fill:

3.Indicate why a DSAP is requested for this particular uncertified applicant.

Information on this application is subject to disclosure pursuant to the Freedom of Information Act.

PAGE 2

ED 177

PART V: ATTESTATION AND SIGNATURE OF EMPLOYING AGENT

The candidate named on this application:

Has been or will be entered into the Connecticut State Department of Education (CSDE) electronic staff file Educator Data System (EDS), with an assignment code appropriate to the endorsement sought under the DSAP.

Will be given special attention in the form of supervision and other assistance, as appropriate.

Signature of Superintendent, Executive Director or Designee

 

 

Date

attesting to accuracy of information

 

 

(Original Signature: No Signature Stamps Accepted)

 

 

Typed or Printed Name of Person Signing Above

 

 

Title

School or District

 

 

Telephone

City

State Zip Code

 

 

 

 

E-mail Address – School or District Contact

 

 

 

Person

Fax

PAGE 3

ED 177

PART VI:

SCHOOL OR DISTRICT REQUEST FOR REISSUANCE OF THE DSAP

1. I hereby request reissuance of a DSAP for the applicant to serve as:

Specific Subject or Field to be Taught Grade Level Endorsement Required for Position

(see endorsement code list)

Check box if bilingual endorsement is sought in above subject.

Indicate language of the bilingual endorsement

PART VII: ATTESTATION AND SIGNATURE OF SCHOOL OR DISTRICT

The candidate named on this application:

Has completed a minimum of nine semester hours of credit in the subject or field requested during the validity period of the previous DSAP.

Has or will be entered into the CSDE Educator Data System (EDS), with an assignment code appropriate to the endorsement sought under the DSAP.

Has successfully served under the previously issued DSAP.

Will be given special attention in the form of supervision and other assistance, as appropriate.

An ED 177 Attachment is being submitted, if enrollment in a program is required for the endorsement.

Signature of Superintendent, Executive Director or Designee

Date

attesting to accuracy of information

 

 

(Original Signature: No Signature Stamps Accepted)

 

 

Typed or Printed Name of Person Signing Above

 

 

Title

School or District

 

Telephone

City

State Zip Code

 

E-mail Address – School or District Contact

 

 

 

Person

Fax

PAGE 4

ED 177 – Attachment

REV. 9/20

CONNECTICUT STATE DEPARTMENT OF EDUCATION

Bureau of Educator Standards and Certification

P.O. Box 150471

Hartford, CT 06115-0471

www.ct.gov/sde/cert

EVIDENCE OF ENROLLMENT IN AN APPROVED EDUCATOR PREPARATION PROGRAM

NOTE: This ED 177 Attachment need not be completed if the candidate holds a valid Connecticut teaching certificate and is completing course work toward a cross endorsement (except for endorsements 102, 112, or 113).

PART A: Verification of Employment (this part must be completed by the employing agent)

Candidate’s Last Name

First Name

 

 

MI

 

 

Social Security Number

Position/Subject or Field

 

 

 

 

 

Grade Level

 

 

Endorsement Required for Position

(see endorsement code list)

Check box if bilingual endorsement is sought in above subject.

Indicate language for the bilingual endorsement

The candidate named above is being considered for a position which requires the completion of course work under a Durational Shortage Area Permit (DSAP).

Signature of Superintendent, Executive Director or Designee

Date

(Original Signature: No Signature Stamp Accepted)

 

 

Typed or Printed Name of Person Signing Above

 

 

Title

School or District

 

 

Telephone

City

State

Zip Code

E-mail Address – School or Disrict Contact Person

PAGE 5

ED 177 – Attachment (continued)

Name of Applicant:

PART B: Evidence of Enrollment or Application to an Approved Planned Educator Preparation Program

Evidence of Enrollment for Admission to an Approved Planned Educator Preparation Program

The above-named candidate is currently enrolled in or has applied and been accepted for admission to a approved planned program leading toward the institution’s recommendation for certification in:

Position/Subject or Field

Grade Level

Date of Enrollment or Date of Acceptance into the Program

Total number of semester hours of credit required to complete this certification program:

Number of semester hours of credit the candidate has already completed:

PART C: Attestation and Signature of the Certification Officer or the Academic Director of the Alternate Route to Certification (ARC) Program

Signature of Certification Officer or

 

 

Date

Academic Director of the ARC Program

 

 

 

 

Typed or Printed Name of Person Signing Above

 

 

 

 

 

 

Title

Educator Preparation Provider (College, University, ARC)

 

 

Telephone

City

State

Zip Code

 

E-mail Address

Mail Completed Form To:

CONNECTICUT STATE DEPARTMENT OF EDUCATION

Bureau of Educator Standards and Certification

P.O. Box 150471

Hartford, CT 06115-0471

Information on this application is subject to disclosure pursuant to the Freedom of Information Act.

PAGE 6

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2. Once your current task is complete, take the next step – fill out all of these fields - CANDIDATE, a Complete Parts I II and III of, b Attach official transcripts, previous DSAP in the subject for, SCHOOL OR DISTRICT OFFICIAL, The application form ED and, a Complete Parts VI and VII of the, b Complete the Evidence of, preparation program or the, EDUCATOR PREPARATION PROVIDER, a Complete the Evidence of, and be completed if the candidate with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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In terms of a Complete Parts I II and III of and a Complete the Evidence of, be certain that you review things in this current part. Both these could be the most important fields in the PDF.

3. This step is generally simple - fill in all the fields in PART I PERSONAL INFORMATION Print, LAST NAME, FIRST NAME, SOCIAL SECURITY NUMBER, ADDRESS Street ONLY no PO Box, CITY, ZIP CODE, PHONE, HomeCell, GENDER, BIRTH DATE MonthDayYear Required, APT, FORMER LAST NAMES, State, and RaceEthnicity to finish this part.

Stage number 3 for submitting connecticut dsap

4. The following subsection requires your involvement in the subsequent parts: Work, EMAIL ADDRESS, Optional, Native American AsianPacific, Have you ever been convicted of, Have you been dismissed for cause, Have you ever surrendered a, including but not limited to an, YES, YES, YES, Pursuant to Connecticut General, and NOTE If you answer YES to any of. Be sure that you fill in all of the required information to move further.

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5. This document needs to be finished by dealing with this segment. Below you will find an extensive listing of form fields that need appropriate details for your form usage to be accomplished: Name of Institution, StateCountry, From To, of Study, Dates Attended, Major Field, Degree Awarded, PART III CANDIDATE ATTESTATION I, By checking the I Agree box you, I Agree SIGNATURE OF CANDIDATE, and DATE.

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