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DEVELOPMENT  \n100 North First Street, E-240 Springfield, Illinois 62777-0001  \nEDUCATOR EFFECTIVENESS DEPARTMENT  \nThis is to certify that the undersigned has completed the professional development activity described herein and that the provider is approved by the state superintendent of education at the time of completion. This form serves as evidence to verify participation in this professional development activity and must be maintained for a period of six years by the licensee and produced if requested as part of an audit.  \nIMPORTANT: THE LICENSEE MUST ENTER THE ACTIVITY INTO THE EDUCATOR LICENSURE INFORMATION SYSTEM (ELIS) BY AUGUST 31 OF THE LICENSE RENEWAL YEAR. LICENSEES RETAIN THIS FORM FOR SIX YEARS FOR AUDITING PURPOSES. DO NOT SUBMIT THE FORM TO ISBE UNLESS THE AGENCY REQUESTS YOU TO DO SO.  \n\n| LEGAL NAME OF PARTICIPANT (Last, First, Middle Initial) | AFFIRMED NAME OF PARTICIPANT (if applicable) (Last, First, Middle Initial) |\n| --- | --- |\n| TITLE OF PROFESSIONAL DEVELOPMENT | IEIN |\n| DATE(S) OF ACTIVITY |  |\n| NAME OF APPROVED PROVIDER (Enter in ELIS) | REGION, COUNTY, DISTRICT, TYPE (RCDT) CODE (Form is invalid without a state-approved provider RCDT code) |\n| NAME OF THIRD-PARTY PRESENTER/ORGANIZATION AUTHORIZED BY A STATE-APPROVED PROVIDER ABOVE (If used) |  |\n| NAME OF PRESENTER(S) (Do not enter into ELIS) |  |\n| NUMBER OF PROFESSIONAL DEVELOPMENT HOURS AWARDED |  |\n\nIS THIS ACTIVITY A STATE-MANDATED TRAINING?  YES  NO  \nSignature of Approved Provider's Representative  \nSignature of Participant's Legal Name  \nSignature of Participant's Affirmed Name (if applicable)","cbCaimUUopqewt0L","https://ap.wps.com/l/cbCaimUUopqewt0L","pdf",318399,"English","# Professional Development Verification Form\n## Participant Information and Activity Details\n## Certification and Compliance Requirements","[{\"question\":\"How long must I retain this form for auditing purposes?\",\"answer\":\"You must maintain this form for a period of six years from the date of completion.\"},{\"question\":\"Where should I enter the information from this form?\",\"answer\":\"You must enter the activity information into the Educator Licensure Information System (ELIS) by August 31 of your license renewal year.\"},{\"question\":\"Should I submit this form to the Illinois State Board of Education (ISBE)?\",\"answer\":\"No, do not submit the form to ISBE unless the agency explicitly requests you to do so.\"}]","77-21B Evidence of Completion for Professional Development | PDF",1791601330]