Ga. Comp. R. & Regs. 160-1-3-.02 app (160-1-3) B
INSTRUCTIONAL PROGRAM WAIVER REQUEST
CHECKLIST
SCHOOL SYSTEM: ___________________________________________
SCHOOL (IF APPROPRIATE): _________________________________
CONTACT PERSON: __________________________________________
TELEPHONE: ____________________FAX: _______________________
E-MAIL ADDRESS: ___________________________________________
Please check the following items that are included in the packet of information.
_____ Resolution of Local Board of Education
_____ rule/requirement being waived
_____ offered in lieu of requirement
_____ duration of waiver
_____ Description of Proposed Activity
_____ goals and objectives
_____ rationale for modification
_____ impact on students, teachers, and school community
_____ staff development
_____ evaluation plan
_____ questions to be answered
_____ data to be collected
_____ method(s) of data collection
_____ data describing current conditions
_____ criteria for determining success
_____ evaluation timeline
_______________________________ ______________________________
Contact Person's Signature Superintendent's Signature
_______________________________ _____________________________
Date
Ga. Comp. R. & Regs. R. 160-1-3-.02 app (160-1-3) B