MCPS Forms: Staff Forms

Montgomery County Public Schools, Rockville, Maryland



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			Related Pages

			MCPS Policies & Regulations Handbook
			Officy of Shared Accoutability

MCPS FORMS > STAFF FORMS

Staff Use

Accounting
ADAAA Accomodations
Benefits
Complaint
Data Request
Educational Services
Electronic Services
Enrollment
Extracurricular Activities
Facilities Management
Food Services
Grant
Health/Safety
Leave Request

Library/Media/Technology
Payroll
Personnel
Professional Development
Professional Growth System
Project Evaluation
Records
Residency Verification
Student
Teacher
Training
Transportation
Tuition Reimbursement
Union

Name	PDF Size	Form Number
Accounting		Back to top
Centralized Investment Fund Deposit/Withdrawal	55 K	280-44
Control Sheet—Check Issuance	93 K	280-27
Fee Waiver Record	107 K	260-1
Field Trip Accounting	301 K	280-41
Journal Voucher	158 K	210-3
Justification	137 K	235-3
MCPS Remittance Slip	106 K	280-34
Monthly Statement of Mileage for Use of Private Vehicle	249 K	220-2
Physical Inventory of Salable School Merchandise	133 K	281-22
Receipt and Bond for Band/Orchestra Instruments	150 K	334-13
Receipt and Bond Form for Equipment Loan	85 K	234-23
Receipt for Donated Items	58 K	275-7
Record of Funds Transmitted to Montgomery County Public Schools	93 K	280-45
Request/Accounting For Over night Travel Funds	78 K	281-1
Request/Authorization for Movement of Funds and/or Positions	102 K	210-1
Schedule of Accounts Receivable/Payable	74 K	281-23
School Reimbursement for MCPS Field Trip Substitute Teacher Coverage	167 K	203-2
Statement of Profit or Loss on Sale of Merchandise	102 K	281-25
Student Financial Obligation	101 K	560-4
Telephone Toll Record	98 K	202-3
Independent Activity Fund (IAF)
Independent Activity Funds - Transfer	88 K	281-46
Independent Activity Funds Report of Payments to MCPS Employees for Personal Services During Calendar Year ____	190 K	280-46
Independent Activity Funds Report of Payments to MCPS Students for Personal Services for the Month of _____	72 K	280-47
Independent Activity Funds Report of Payments to Independent Contractors (Persons who are neither MCPS Employees nor MCPS Students) for Personal Services for the Month of _____	84 K	280-47A
Independent Activity Funds Request for a Purchase	67 K	280-54
Independent Activity Funds Sponsor's Record	252 K	281-21
Request for Reimbursement of Invoices Paid by School	216 K	280-48
School Financial Report - Independent Activity Funds	62 K	281-24
Tickets and Cash Report of Admissions Manager	126 K	280-50
Purchasing Card
Purchasing Card Approving Official Acknowledgement	78 K	234-22
Purchasing Card Card Member Transaction Log	62 K	234-21
Purchasing Card File Maintenance Worksheet	87 K	234-20
ADAAA Accommodations		Back to top
Employee/Member of the Public Request For ADAAA Accommodation/Modification	85 K	270-6
Benefits		Back to top
Acknowledgement of Medicare Enrollment Requirements for All Disability Retirees	76 K	455-14
Designation of Beneficiaries	84 K	455-5
Employee Benefit Plan Enrollment	218 K	455-20
Membership Information Montgomery County Public Schools Employee Pension System	59 K	455-3
Request for Estimate of Retirement Benefits	90 K	455-2A
Retiree Benefit Plan Enrollment	117 K	455-22
Transfer of Cumulative Sick Leave	119 K	430-62
Complaint		Back to top
Administrative Complaint	108 K	430-42
Data Request		Back to top
Ad Hoc Student Data Request	68 K	365-47
Request for Information or Support	98 K	365-54
Educational Services		Back to top
Educational Management Team Summary	77 K	272-4
Referral for Alternative Program Placement	128 K	336-55
ESOL
Bilingual Assessment Team Referral Checklist	187 K	336-26
Referral for ESOL Counseling	112 K	335-60
Referral for ESOL Parent Outreach	124 K	320-49
Report of Language Line Use from a NonMCPS Telephone	61 K	202-2
Request for Interpretation Services	115 K	311-10
Request For Written Translations	106 K	311-1
Evaluation
Referral for OT/PT Review/Assessment	96 K	336-27
Pre-kindergarten/Head Start Speech-Language Screening Instrument	218 K	335-37
Home and Hospital Teaching
Home and Hospital Teaching Unit Teacher Questionnaire	95 K	311-21
Homeless Students
Homeless Status	104 K	335-77
Parent Letter: Recommended School	46 K	335-77A
Homeless Student Transportation Action Request (HSTAR)	218 K	335-77B
MSDE Education of Homeless Children and Youth	111 K	335-77C
Section 504 Plan
Authorization for School Psychologists Attentional Disorders Assessment	134 K	270-2a
Section 504 Evaluation CONFIDENTIAL	283 K	270-2B
Section 504 Plan (Confidential)	118 K	270-2
Section 504 Progress and Accommodation Review Worksheet	57 K	270-2c
Testing Accommodations for Section 504 Students	131 K	336-41b
Special Education
Addendum To MCPS Forms	43 K	336-01
Authorization for Assessment (Confidential)	197 K	336-31
Authorization for Release of Confidential Information	86 K	336-32
Change of Placement and Manifestation Determinations (Confidential)	113 K	336-63
Classroom Observation	192 K	336-21
Documentation of Parental Request to Delay Initial Eligibility for Special Education Determination	113 K	336-46
Educational History (Confidential)	100 K	336-20
Elementary Teacher Report for IEP Team Meetings	190 K	272-7
Elementary Teacher Report for Quarterly Progress	135 K	272-5
Eligibility Screening: Parent Interview/Questionnaire	219 K	336-22
Parent Report	110 K	336-39
Physical Disabilities Program	100 K	336-24
Prekindergarten Observation	77 K	336-21a
Prekindergarten Teacher Questionnaire	222 K	272-1
Secondary Teacher Report for IEP Team Meetings	141 K	272-8
Secondary Teacher Report for Quarterly Progress	133 K	272-6
Special Education Staffing Notes (Confidential)	82 K	336-52
Speech/Language Screening Summary	83 K	336-25
Student Screening Profile Worksheet	107 K	336-23
Teacher Referral	207 K	272-9
Student Behavior
Behavioral Intervention Plan	120 K	336-65
Functional Behavioral Assessment	91 K	336-64
Electronic Services		Back to top
Application Change Request Form	86 K	310-74
EPIC CD-ROM/Computer Software Record of Evaluation	99 K	365-29
Request for an MCPS E-Mail Account	149 K	271-4A
Web Services Request	94 K	271-5
Webmaster Account Request	98 K	271-7
Enrollment		Back to top
Educational Interview for Student - Permanent Withdrawal	246 K	565-4
Elementary Student Withdrawal/Clearance	182 K	560-20
Maryland Student Withdrawal/Transfer Record	121 K	SR7
School Truancy Referral	169 K	560-11
Secondary Student Withdrawal/Clearance Form	189 K	560-21
Verification of Enrollment	171 K	226-19
Extracurricular Activities		Back to top
Change to Annual Plan for Extracurricular Activities FY _____	108 K	430-58
Elementary School Extracurricular Activities Annual Plan FY _____	116 K	430-84
Extracurricular Activities Annual Plan—Class 1 FY _____	177 K	430-54
Extracurricular Activity Assignment	84 K	430-59
Extracurricular Activities Whose Sponsor Has Not Been Determined	74 K	430-83
High School Extratcurricular Activities Annual Plan FY _____	270 K	430-57
High Schools Extracurricular Activities Summer Athletic Practice	154 K	430-61
Middle School Extracurricular Activities Annual Plan FY _____	194 K	430-60
Senior High Schools Extracurricular Activities Annual Plan	321 K	430-57
Facilities Management		Back to top
Computer Equipment Delivery Request	68 K	234-5
Delivery Request	73 K	234-9
Elementary Physical Education Indoor/Outdoor Equipment Status Report	392 K	345-23A
Furniture/Equipment Inventory Property Report: Addition/Correction	73 K	234-18
Furniture/Equipment Inventory Property Report: Delete	146 K	234-17
Repair/Delivery Request	31 K	234-3
School Energy and Recycling Team (SERT) Action Plan	117 K	201-10
Food Services		Back to top
Child Care Food Program Cycle Menus and Change Report	108 K	240-53
Child Care Food Program - Infant Menu	108 K	240-56
Child Care Food Program Menu	109 K	240-55
Monthly Invoice Child and Adult Care Food Program	125 K	240-54
Notice of Change in Enrollment Child and Adult Care Food Program	173 K	240-50
Summary Report of Monthly Claim Discrepansies – Child Care Food Program	93 K	240-58
Grant		Back to top
Application for a Small Grant	112 K	280-71
Application for Extended Technology Hours Grant	127 K	280-73
Approval to Submit Proposal for Grant Funding	116 K	280-60
Information on School Based Small Grant Award	47 K	280-71A
Health/Safety		Back to top
BLOODBORNE PATHOGENS EMPLOYEE TRAINING Record of Training Attendance	64 K	230-30
BLOODBORNE PATHOGENS EMPLOYEE TRAINING Record of Training Attendance Continuation Sheet	73 K	230-30a
Building Sevices Indoor Air Quality Checklist	174 K	230-24
Bus Accident Reporting Checklist	133 K	215-51
Certification of Physician or Health Care Provider	106 K	440-35
Crisis Center Referral Information	89 K	560-10
Documentation of Physical Interventions or Seclusion	113 K	337-2
Family Life and Human Sexuality (FLHS) and Disease Prevention and Control (DPC) Worksheet Annual Report—Elementary School	101 K	345-30A
Family Life and Human Sexuality (FLHS) and Disease Prevention and Control (DPC) Worksheet Annual Report—Middle School	104 K	345-30B
Family Life and Human Sexuality (FLHS) and Disease Prevention and Control (DPC) Worksheet Annual Report—High School	106 K	345-30C
Health Care Professional's Written Opinion (Confidential)	63 K	230-34
Hepatitis B Virus Vaccination Authorization (Confidential)	55 K	230-32
Indoor Air Quality Complaint	39 K	230-23
Operators's Accident Report	166 K	215-49b
Report of Suspected Child Abuse, Neglect, and Mental Injury	223 K	335-44
School Fire Evacuation Drill Log	100 K	230-1
Student Accident Report	107 K	525-2
Student Referral	53 K	555-1
Suicide Risk Reporting Form	189 K	335-54
Supervisor's Accident Report	218 K	215-49a
Leave Request		Back to top
Leave Request (NOT Requiring ERSC Authorization) 1 form per page	68 K	430-1A
Leave Request (NOT Requiring ERSC Authorization) 2 forms per page	86 K	430-1A
Leave Request (Requiring ERSC Authorization)	151 K	430-1
Professional Leave (PRO)	53 K	430-94
Library/Media/Technology		Back to top
Application for Extended Technology Hours Grant	117 K	280-73
Evaluation and Selection of Instructional Materials Copyright Permission	105 K	203-1
Media Purchase Order (Processing Services)	65 K	235-26A
Periodical Purchase Order (Professional Library)	21 K	235-26B
Media Purchase Order - Professional Library	29 K	235-26C
Professional Library Media Order	27 K	365-5
Record of Evaluation of Instructional Materials	162 K	365-25
Request For Advance Payment (Professional Library)	68 K	365-9A
Request for Professional Materials Reimbursement to MCPS Employee	22 K	365-41
Request for Waiver for the Instructional Use of Film	99 K	365-21
Video Request	84 K	365-37
Videotape Duplication Request	121 K	365-28
Payroll		Back to top
Authorization for Employee Use of Overtime	76 K	280-19
Direct Deposit Authorization	154 K	280-31
Employee’s Additional Withholding of Income Tax Agreement	70 K	280-3
MCPS Employees’ Retirement/Pension System Federal and Maryland State Withholding Request	149 K	281-50
Payroll Attendance Collection System Access Request	129 K	280-63
Request for Advanced Salary Placement	124 K	475-1
Teacher's Biweekly Report of Home and Hospital Teaching	156 K	311-13
W4-MW-507: Employee's Withholding Allowance Certificate	116 K	W4-MW-507
Timesheet
PACS Correction	322 K	280-7
PACS Time Sheet	182 K	430-70
PACS Timesheet for ECA Class 3-5 Activities Dollars Only	76 K	430-18
PACS Timesheet Short-Term Substitute Teachers and Staff Development Substitute Teachers	206 K	430-17
PACS Timesheet for MCEA and MCAAP Employees with Required Summer Workdays	153 K	430-13
PACS Timesheet Temporary Part Time	149 K	430-12
Payroll Timesheet Extracurricular Class 1 or Class 2 Activities	144 K	430-21
Payroll Timesheet Total Hours Summary Timesheet Home and Hospital Teaching	190 K	311-19
Personnel		Back to top
Application for Retirement (Retirement or Pension System)	155 K	455-2
Authorization Form Emergency Class Coverage Program	100 K	430-10
Change In Personal Information	150 K	445-1
Clearance Form for Central Office Staff	93 K	220-3
Credit Applicability Verification	686 K	440-5
Employee Change Request	171 K	426-1
Job Banding Career Advancement	89 K	336-84
Notice of Termination of Employment from Montgomery County Public Schools	63 K	480-4
Notification of Change in Hours/Title	58 K	447-6
Paraeducator Involuntary Transfer/Hour Form	297 K	425-9A
Position Change	244 K	447-13
Professional Preference for Reassignment	167 K	425-52
Professional Reference—Counselor	219 K	445-50
Professional Reference—School Psychologist	254 K	445-15
Professional Reference (Teacher Level)	105 K	445-16
Recommendation for Social Worker Position	225 K	430-92
Reference for Applicant for: IRT/Resource Teacher (Secondary), Resource Counselor, Media Specialist, Counselor, Reading Specialist	112 K	430-48
Request for Approval of Substitute (Non-classroom Teacher Positions)	81 K	430-22
Return to Work Evaluation	232 K	440-40
Request for Outstanding Service Award	92 K	460-9
Statement of Military Service	90 K	455-18
Student Teacher/Intern Assignment Verification	76 K	440-12
Substitute Teacher/Home Instruction Preferences	143 K	440-10
Supporting Services Involuntary Transfer Request	85 K	425-9
Teacher Assignment	32 K	440-6
Teacher-Level Involuntary Transfer Request	146 K	425-7
Employment
Applicant Population Record	82 K	460-27A
APPLICATION FOR ADVERTISED POSITION (Current MCPS employees – including temporary and substitute supporting service employees)	173 K	446-6
Application for Counselor Internship or Practicum Experience	88 K	445-49
Application for: IRT/Resource Teacher/Counselor, Media Generalist, Counselor, Reading Specialist	604 K	430-47
Application for Summer Employment	84 K	460-25
Employment Application	397 K	460-27
Interest in an Advertised Vacancy	141 K	460-32
Long-Term Substitute Request for Employment or Notice of Termination	131 K	445-17
Reference For Supporting Services Employees	174 K	445-10
Request for Summer Employment (for MCEA Members)	91 K	460-39
Request For Temporary Employment	255 K	460-2
Verification of Employment	47 K	460-29
Evaluation
Administrative and Supervisory Professional Growth System Final Evaluation Report for Assistant Principals, Assistant School Administrator, and Coordinators of School-Based Programs	30 K	430-80
Administrative and Supervisory Professional Growth System Final Evaluation Report for Business and Operations Administrators	26 K	430-95
Final Evaluation Report for Central Services Administrators	29 K	430-74
Final Evaluation Report Montgomery County Infants and Toddlers (MCITP) Early Interventionists	68 K	425-49
Final Evaluation Report for Principals	34 K	430-69
Final Evaluation Report: High School Resource Teacher	85 K	425-48
Final Evaluation Report: Occupational/Physical Therapist	134 K	425-46
Final Evaluation Report: Resource Counselor	98 K	425-47
Final Evaluation Report: Instructional Specialist	117 K	425-44
Final Evaluation Report: Speech-Language Pathologist	119 K	425-43
School Counselor Final Evaluation	144 K	430-45
Professional Development		Back to top
Administrators and Supervisors' Professional Development Plan (Word Document)	57 K	425-50
Continuing Professional Development Experiences (CPDE)	63 K	440-7
End of Professional Development Cycle Review Form	94 K	425-37
Five-Year Certificate Renewal Plan for the Standard Professional Certificate 2 to obtain the Advanced Professional Certificate (APC)	98 K	440-36
Five-Year Professional Development Plan for Renewal of The Advanced Professional Certificate	124 K	440-37
Professional Development Plan (PDP)	148 K	425-35
Professional Development Plan Progress Check Point	80 K	425-36
School Counselor Professional Development Plan (PDP)	235 K	425-41
Professional Growth System		Back to top
Professional Growth System Final Evaluation Report: Library Media Specialist	146 K	430-79
Professional Growth System Final Evaluation Report: Pupil Personnel Worker (PPW)	68 K	425-42
Professional Growth System Final Evaluation Report: Reading Specialist	149 K	425-51
Professional Growth System Final Evaluation Report: Reading Specialist (Word Document)	40 K	425-51
Professional Growth System Final Evaluation Report: School Psychologist	73 K	425-45
Professional Growth System Final Evaluation Report: Staff Development Teacher (SDT) (C.5 and above)	135 K	425-40
Professional Growth System Final Evaluation Report: Teacher	119 K	425-39
Professional Growth System Post-Observation Conference Report	86 K	425-38
Supporting Services Professional Growth System Evaluation Form	170 K	430-90
Project Evaluation		Back to top
Request for Project Evaluation or Outcome Reporting	44 K	370-1
Records		Back to top
Central Records Storage/Shredding Request Form	108 K	365-10
Residency Verification		Back to top
Documentation of Residency Through Home Visit	360 K	560-34
Student		Back to top
Children in Informal Kinship Care Relationships – As of December 31 –	128 K	560-40A
Children in Out-of-County Living Arrangements – As of December 31 –	131 K	560-40
Request for Student Labels or Listings	167 K	226-10
Student Sign In/Sign Out Sheet	95 K	560-1
Student Records Review and Update Verification Certification Statement	91 K	226-7
Student Transfer Outside of MCPS or Death of Student	97 K	565-5
Student Discipline
Documentation of Interventions	114 K	272-10
Documentation of Seclusion or Physical Restraint	121 K	337-2
Bullying, Harassment, or Intimidation Incident School Investigation Form	153 K	230-36
Report of A Serious School Incident	163 K	270-3
School Bus Disciplinary Report	212 K	555-3
Worksheet for Suspension or Health-Related Exclusion	481 K	560-6
Teacher		Back to top
Application to Supervise a Counseling Practicum Student or Intern	112 K	440-12A
Athletic Roster: Secondary School	194 K	345-45
Authorization Form Emergency Class Coverage Program	100 K	430-10
Clearance Sheet	123 K	325-17
Deletion of Student Service Learning (SSL) Hours	82 K	560-54
Elementary Physical Education Teacher Data Sheet	193 K	345-31
General Use Slip	66 K	275-2
Model Rocket Activity Authorization	87 K	201-11
Pilot Course Proposal	149 K	560-56
Prekindergarten Teacher Questionnaire	222 K	272-1
Request for Assignments	73 K	301-2
Summary of Parent Conference	61 K	270-1
Verification of Equivalent Activities for Advanced Professional Certificate (APC) Renewal Purposes	129 K	440-34
Weekly Record of Time of Teacher's Arrival and Departure	262 K	430-11
Yearly Evaluation Report	35 K	430-66
Volunteering
Connection Resource Bank Request	66 K	311-61
Connection Resource Mentor Request	53 K	311-62
Teacher Volunteer Planning Center	63 K	311-52
Volunteer Sign in Log	252 K	311-56
Training		Back to top
In-Service Attendance Report	118 K	215-39
Registration for Building Service Staff Inservice Training	36 K	440-18
Registration for Support Service Inservice Training	34 K	440-4
Request for Released Time to Attend Class for Supporting Services Staff	147 K	440-21
Transportation		Back to top
Foster Student Transportation Action Request (FSTAR)	187 K	336-42A
Notice of Violation	75 K	215-14
Student Transportation Action Request (STAR)	166 K	336-42
Supplemental Accident Information	301 K	215-50
Union		Back to top
MCAAP/MCBOA Members Designation of Annual Leave to Contribute to 403(b) Plan	121 K	430-91
MCAAP/MCBOA/MCPS Grievance Form	186 K	430-43
MCEA Grievance Form	104 K	430-41
MCPS/MCCSSE Grievance	616 K	430-40
Nominations/Request	148 K	430-93
Required Representation Fee For Supporting Services Personnel	53 K	430-44
SEIU Local 500 Sick Leave Bank Opt-Out	104 K	280-38
SEIU Members Election Cash Out Sick Leave Hours for Perfect Attendance	81 K	280-36
Union Business Leave (UBL)	67 K	430-5


	For questions regarding forms, call Harriet Potosky at (301) 279-3538. Updated February 1, 2010 \| Maintained by Missy Gumula


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