State of Tennessee

Tutoring Services Facility Pre-Approval & Agreement Form

This form must be submitted and approved by the Tennessee Department of Education (the department) before IEA funds can be used to pay for any tutoring services.

IEA account holders must submit a new form each IEA contract year, for each tutoring facility.

Before submitting this form, please read Chapter 6 of the IEA Account Holder Handbook to ensure the information provided on this form meets the IEA Program requirements.

In addition, by signing this document, the IEA account holder verifies that the tutoring facility complies with the IEA rules, procedures, and other requirements set in the IEA Account Holder Handbook regarding the criminal background check requirements.

SBE Rule 0520-01-11-.02(7) requires, at a minimum, a criminal background check for IEA tutoring and therapy providers include:

a check of the Tennessee Sex Offender Registry;
a check of the Tennessee Department of Health’s Abuse Registry, and
a fingerprint-based criminal history records check conducted by the Tennessee Bureau of Investigation (TBI) and forwarded by the TBI to the Federal Bureau of Investigation (FBI).

The department does not endorse any products, providers, services, etc. The department only determines whether the tutoring facility and services listed on this form meet the qualifications outlined in the IEA Account Holder Handbook.

Please allow up to 5 business days for the department to process this form.

Tennessee Department of Education
Individualized Education Account (IEA) Program
Andrew Johnson Tower, 9th Floor
710 James Robertson Parkway • Nashville, TN 37243
Tel: (615) 253-3781• Fax: (615) 741-6793

ED5518 RDA 11163

Directions: Please provide the information in the fields below.

Student Name*

First Name

Last Name

Account Holder Name*

First Name

Last Name

Account Holder Email Address*

Date*

Tutoring Subject Area(s)

IEA funding may be used to hire tutors for the approved subject areas listed in the IEA Account Holder Handbook. Please indicate the subject area(s) for which the tutoring will be provided. If you would like to request a subject area not listed, please submit the Tutor Subject Add Request Form.

Tutoring Subject Area*

Computer technology (including computer applications, computer literacy, computer programming, and interactive multimedia design) Fine arts (including music theory and art theory) English language arts (including reading) Health education Mathematics (including algebra I, algebra II, geometry, calculus, trigonometry, pre-calculus, statistics) Personal finance Science (including biology, chemistry, physics, physical science, anatomy and physiology, earth science, geology, environmental science, ecology) Social studies (including economics, psychology, sociology, U.S. history, world history, geography, ancient history, African American history, U.S. government and civics) World language

Tutoring Facility Information

Facility Name*

Subject Area(s)

Accreditation

Phone Number*

Email Address*

Business Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Accrediting Agency: The tutoring facility information on this form must match what is listed in the accrediting agency’s directory.*

Any accreditation division of Cognia/AdvancED: the North Central Association Commission on Accreditation and School Improvement (NCA CASI), the Northwest Accreditation Commission (NWAC), and the Southern Association of Colleges and Schools Council on Accreditation and School Improvement (SACS CASI) – to check accreditation, go to: http://www.advanc-ed.org/oasis2/u/par/search. Middle States Association of Colleges and Schools (MSA) – to check accreditation, go to: http://www.msa-cess.org/default.aspx?RelID=606553. New England Association of Schools and Colleges (NEASC) – to check accreditation, go to: https://www.neasc.org/find-member-schools. Western Association of Schools and Colleges (WASC) – to check accreditation, go to: http://directory.acswasc.org/. Council on Occupational Education (COE) - to check accreditation, go to http://council.org/membership/.

Supporting Documentation

It is optional, but recommended, to submit a fee schedule for the tutoring facility.

Proof of the tutoring facility’s credentials/accreditation

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Fee Schedule

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IEA Account Holder Agreement

By signing your initials, you are acknowledging your agreement to each statement.

I understand that the use of IEA funds must be for the sole benefit of the participating student for which the IEA account is established.

Initials*

I understand that it is my responsibility to notify the department if any of the information reported in this form changes.

Initials*

I certify that the provider requires criminal background checks pursuant to the Rules of the State Board of Education Chapter 0520-01-11.

Initials*

I understand that it is a conflict of interest and against IEA Program rules and procedures for a family member of a participating student, including step parent or a member of a participating student’s household, to provide services or professional recommendations.

Initials*

I certify the information provided in this form, including any supporting documentation is truthful and accurate. I further understand that any false statements or documentation may result in the student’s account being frozen, the student being removed from the IEA Program, closure of the student’s IEA account, and/or forfeiture of all funds remaining in the account. I further understand that if any false statements or documentation is provided, the department may prohibit the student and/or parent/guardian from enrolling in the IEA Program and/ or being an IEA account holder in future.

Initials*

IEA Account Holder Signature*

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Use your mouse or finger to draw your signature and date above

Date*