Tutoring Services 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 provider.

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.

Account holders must submit to the department proof of the tutor’s credentials/accreditation with this form.

  • For use of IEA funds, tutoring services must be provided by an individual tutor who holds one of the qualifications listed in the IEA Account Holder Handbook or an accredited tutoring organization as explained in the IEA Account Holder Handbook (credentials must be in the subject area for which the tutor will be providing tutoring services). 
  • In addition, by signing this document, the IEA account holder verifies that the tutor 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:

  1. a check of the Tennessee Sex Offender Registry;
  2. a check of the Tennessee Department of Health’s Abuse Registry, and
  3. 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 tutor and tutoring 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

ED5517 11163

Directions: Please provide the information in the fields below.

Student Name*
Account Holder Name*
Date*

Tutoring Subject Area(s)

IEA funds may be used to pay certified tutors for the approved K-12 subject areas listed in the IEA Account Holder Handbook.  Place an ‘X’ in the ‘Check Box’ column next to the subject areas 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*

Individual Tutor Information

Tutor Name*
Business Address*
Individual Tutor Credentials: Select the credential that the tutor has.*
• If the license was issued by the Tennessee Department of Education, the tutor name and credentials must match what is in the Tennessee teacher license system (TNCompass) which you can access by going to: https://tdoe.tncompass.org/Public/Search. • If the license was issued by another state, you must attach a copy of the out-of-state teaching license.
Does the tutor name and credentials match what is in the Tennessee teacher license system (TNCompass), which you can access by going to: https://tdoe.tncompass.org/Public/Search?*

Supporting Documentation

Along with this completed form, proof of the tutor’s credentials/accreditation must be attached, unless the tutor has a valid Tennessee teaching license and then the license number provided above will suffice. The following documents are acceptable proofs of accreditation:

  • National Board Certificate
  • Praxis score reports for applicable subjects
  • College transcript or diploma
  • Copy of the out-of-state teaching license

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

National Board Certificate*
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Praxis score reports for applicable subjects*
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College transcript or diploma*
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Copy of the out-of-state teaching license*
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Supporting documentation
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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.

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

I certify that the provider has completed a criminal background check pursuant to the Rules of the State Board of Education Chapter 0520-01-11.

I certify that the provider has never been convicted of a felony, including conviction on a plea of guilty, a plea of nolo contendere or order granting pre-trial diversion.

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 stepparent or a member of a participating student’s household, to provide services or professional recommendations.

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.


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