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Fill Your Connecticut Ed 177 Form

The Connecticut Ed 177 form is an application for the Durational Shortage Area Permit (DSAP), which allows schools to hire candidates when no appropriately certified individuals are available. This form must be submitted by the employing agent before the first day of employment, ensuring that all necessary requirements are met. If you need to fill out this form, click the button below to get started.

Prepare Connecticut Ed 177 Here

Article Structure

The Connecticut Ed 177 form serves as an essential application for obtaining a Durational Shortage Area Permit (DSAP), which is crucial for educational institutions facing difficulties in filling specific teaching positions with appropriately certified candidates. This form cannot be initiated by the applicant; instead, it must be submitted by the employing school or district official. The application process requires the completion of various sections of the form, including personal information and educational qualifications. Candidates must provide official transcripts demonstrating completion of at least 12 semester hours in the relevant subject area, along with a bachelor’s degree if they have never held certification in Connecticut. Additionally, school or district officials must ensure that all required documentation is submitted to the Bureau of Educator Standards and Certification before the candidate's first day of employment. The effective date of the DSAP can be backdated to the date the form is received, provided all criteria are met. The Ed 177 form also includes a checklist to guide both candidates and school officials through the necessary steps, ensuring compliance with Connecticut regulations. Understanding the requirements and process outlined in the Ed 177 form is vital for both educators and administrators to navigate the complexities of educator certification in Connecticut.

Documents used along the form

The Connecticut Ed 177 form is a crucial document for those seeking a Durational Shortage Area Permit (DSAP) in the state. However, it is often accompanied by other important forms and documents that help streamline the application process. Below is a list of some commonly used documents along with a brief description of each.

Evidence of Enrollment (Part A): This attachment is completed by the employing agent and must be signed by a higher education official. It confirms that the candidate is enrolled in a teacher preparation program or an Alternate Route to Certification program, which is necessary for those applying for a DSAP.
Evidence of Enrollment (Part B and C): Similar to Part A, these sections are filled out by the educator preparation provider. They provide verification of the candidate's enrollment and progress in the necessary coursework to fulfill DSAP requirements.
Official Transcripts: Candidates must submit official transcripts as part of their application. These transcripts should demonstrate that the candidate has completed the required semester hours of credit in the relevant subject area for which the DSAP is requested.
Colorado Power of Attorney Form: For individuals needing to manage affairs legally, consider utilizing the Colorado Power of Attorney resource to ensure sound decision-making and compliance.
Application for Reissuance of the DSAP: If a candidate has previously held a DSAP and is seeking to renew it, this application must be completed. It requires updated information and documentation to ensure the candidate still meets the eligibility criteria.

These documents work in conjunction with the Connecticut Ed 177 form to ensure that the application process for a DSAP is thorough and efficient. Properly completing and submitting these forms is essential for candidates seeking to fill teaching positions in shortage areas within Connecticut's educational system.

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Preview - Connecticut Ed 177 Form

		INSTRUCTIONS – PAGE 1
	ED 177	CONNECTICUT STATE DEPARTMENT OF EDUCATION
	REV. 9/20	Bureau of Educator Standards and Certification
	C.G.S. 10-145	P.O. Box 150471
	C.G.S. 10-145d	P.O. Box 150471
	C.G.S. 10-145d	Hartford, CT 06115-0471
	Regs. 10-145d-421, 422	Hartford, CT 06115-0471
	Regs. 10-145d-421, 422
		www.ct.gov/sde/cert
		INSTRUCTIONS FOR FORM ED 177

APPLICATION FOR FIRST ISSUANCE OF THE DURATIONAL SHORTAGE AREA PERMIT (DSAP)

A Durational Shortage Area Permit (DSAP) may be requested by the school or district if a position cannot be filled by an appropriately certified candidate. An application for issuance of a DSAP cannot be initiated by the applicant. The effective date of the DSAP may be the date the original ED 177 is received, provided all requirements for issuance have been met on or before this date. An

ED 177 must be submitted prior to the first day of employment.

Please complete the appropriate section of the checklist below.

CANDIDATE

a. Complete Parts I, II, and III of the application form (ED 177).

b. Attach official transcripts showing the completion of at least 12 semester hours of credit in the subject for which the DSAP is requested. An official transcript showing the completion of a bachelor’s degree must be included if the candidate has never held certification in Connecticut.

SCHOOL OR DISTRICT OFFICIAL

The application form (ED 177) and supporting documentation must be submitted by the employing agent to the Bureau of Educator Standards and Certification. The “Evidence of Enrollment” form ED 177 (Attachment) may be submitted separately.

a. Complete Parts IV and V of the application form (ED 177).

b. Complete the “Evidence of Enrollment” form ED 177 (Attachment) – Part A, if applicable. If this part is required, return the

Attachment to the candidate for signature by the appropriate higher education official where the candidate is enrolling in a teacher preparation program or the Alternate Route to Certification program. The Attachment need not be completed if the candidate holds a valid Connecticut certificate and is completing course work under a DSAP to fulfill requirements for a cross endorsement (except for endorsements 102, 112 or 113), or if the candidate has at least 20 school months of successful appropriate* teaching experience in an approved nonpublic school.

EDUCATOR PREPARATION PROVIDER

a. Complete the “Evidence of Enrollment” form ED 177 (Attachment) – Part B and Part C, if applicable. The Attachment need not be completed if the candidate holds a valid Connecticut educator certificate and is completing course work under a DSAP to fulfill requirements for a cross endorsement (except for endorsements 102, 112 or 113), or if the candidate has at least 20 school months of successful appropriate* teaching experience in the same approved nonpublic school.

*The twenty months must be in the subject area or field for which the initial educator certificate will be sought (CT State Regulation 10-145d-412 (3)(A)).

		INSTRUCTIONS – PAGE 2
	ED 177	CONNECTICUT STATE DEPARTMENT OF EDUCATION
	REV. 9/20	Bureau of Educator Standards and Certification
	C.G.S. 10-145	P.O. Box 150471
	C.G.S. 10-145d	P.O. Box 150471
	C.G.S. 10-145d	Hartford, CT 06115-0471
	Regs. 10-145d-421, 422	Hartford, CT 06115-0471
	Regs. 10-145d-421, 422
		www.ct.gov/sde/cert

APPLICATION FOR REISSUANCE OF THE DURATIONAL SHORTAGE AREA PERMIT (DSAP)

A Durational Shortage Area Permit (DSAP) may be requested by the employing agent of a board of education if a position cannot be filled by an appropriately certified candidate. An application for issuance of a DSAP cannot be initiated by the applicant. The effective date of the DSAP will be the date the original ED 177 is received, provided all requirements for issuance have been met on or before this date. An ED 177 must be submitted prior to the first day of employment.

The following checklist outlines the sections of the form to be completed and documents which must be submitted by the employing agent in order for the Bureau of Educator Standards and Certification to determine eligibility for a DSAP.

CANDIDATE

a. Complete Parts I, II, and III of the application form (ED 177).

b. Attach official transcripts showing the completion of at least nine semester hours of credit during the validity period of the previous DSAP in the subject for which the DSAP is requested.

SCHOOL OR DISTRICT OFFICIAL

The application form (ED 177) and supporting documentation must be submitted by the employing agent to the Bureau of Educator Standards and Certification. The Attachment may be submitted separately.

a. Complete Parts VI and VII of the application form (ED 177).

b. Complete the “Evidence of Enrollment” form ED 177 (Attachment) – Part A, if applicable. If this part is required, return the

EDUCATOR PREPARATION PROVIDER

*The twenty months must be in the subject area or field for which the initial educator certificate will be sought (CT State Regulation 10-145d-412 (3)(A)).

INSTRUCTIONS – PAGE 3

ED 177

CONNECTICUT ENDORSEMENT CODES

Teaching Endorsements

010Business, 7–12

015English, 7–12

018French, 7–12

019German, 7–12

020Italian, 7–12

021Latin, 7–12

022Russian, 7–12

023Spanish, 7–12

024Other World Language, 7–12

026History & Social Studies, 7–12

029Mathematics, 7–12

030Biology, 7–12

031Chemistry, 7–12

032Physics, 7–12

033Earth Science, 7–12

034General Science, 7–12

035Driver Education

040Agriculture, Pre-K–12

041Vocational Agriculture, 7–12

042Art, PK–12

043Health, P –12

044Physical Education, PK–12

045Home Economics, PK–12

047Technology Education, PK–12

049Music, PK–12

055Partially Sighted, PK–12

057Deaf and Hard of Hearing, PK–12

059Blind, PK–12

062School Library Media Specialist

072 School Nurse-Teacher

073School Dental Hygienist-Teacher

089Marketing Education, 7–12

101World Language Instructor, Elementary

102Remedial Reading & Remedial Language Arts, 1–12

104Cooperative Work Education/Diversified Occupations

110Unique Subject Area

111Teaching English to Speakers of Other Languages (TESOL), PK–12

112Integrated Early Childhood/Special Ed., Birth – Kindergarten

113Integrated Early Childhood/Special Ed., Nursery -K–Elem. 1–3

165Comprehensive Special Education, K–12

215English, Middle School

226History & Social Studies, Middle School

229Mathematics, Middle School

230Biology, Middle School

231Chemistry, Middle School

232Physics, Middle School

233Earth Science, Middle School

234General Science, Middle School

235Integrated Science, Middle School

305Elementary, 1 – 6

317Portuguese, 7–12

318Mandarin Chinese, 7–12

483Dance, Pre-K–12

485Theatre and Drama, Pre-K–12

511Montesori, Elementary, 1–6

512Montesori, Primary, Birth to Kindergarten

826Vocational Department Head: Trade Technology

Administrative Endorsements		Adult Education Endorsements
		Adult Education Endorsements
085	School Business Administrator	088	Non-English Speaking Adults
092	Intermediate Administration or Supervision	106	High School Credit Diploma Program
093	Superintendent of Schools	107	External Diploma Program/Noncredit Mandated Programs
097	Reading and Language Arts Consultant
105	Department Chairperson

Special Services Endorsements
061	Speech and Language Pathologist	Vocational Endorsements
068	School Counselor	082	Vocational Technical Administrator
070	School Psychologist	090	Occupational Subject, Vocational Technical Schools
071	School Social Worker	091	Trade-Related Subjects, Vocational Technical Schools
268	School Marriage and Family Therapist	098	Trade & Industrial Occupations – Comprehensive High School
		103	Health Occupations – Comprehensive High School
		108	Practical Nurse Education Instruction

NOTE: Bilingual codes are not provided. Check appropriate box on application to request a bilingual endorsement.

PAGE 4

	ED 177	CONNECTICUT STATE DEPARTMENT OF EDUCATION
	REV. 9/20	Bureau of Educator Standards and Certification
	C.G.S. 10-145	P.O. Box 150471
	C.G.S. 10-145d	P.O. Box 150471
	C.G.S. 10-145d	Hartford, CT 06115-0471
	Regs. 10-145d-421, 422	Hartford, CT 06115-0471
	Regs. 10-145d-421, 422	www.ct.gov/sde/cert
		www.ct.gov/sde/cert

APPLICATION FOR DURATIONAL SHORTAGE AREA PERMIT (DSAP)

PART I: PERSONAL INFORMATION (Print all information in blue ink and in uppercase letters.)

LAST NAME

FIRST NAME

˗ ˗

SOCIAL SECURITY NUMBER

ADDRESS (Street ONLY, no P.O. Box)

CITY

ZIP CODE

MIGENDER ˗ ˗

BIRTH DATE (Month-Day-Year) - Required

APT. #

(State)

FORMER LAST NAME(S)

PHONE

(Home/Cell)

Race/Ethnicity

(Work)

(Optional)

E-MAIL ADDRESS

Have you ever been convicted of any crime, excluding minor traffic violations?

YES

Have you been dismissed for cause from any position?

YES

Have you ever surrendered a professional certificate, license, permit or other credential

YES

(including, but not limited to, an education credential); had one revoked, suspended,

annulled, invalidated, rejected or denied for cause; or been the subject of any other

adverse or disciplinary credential action?

1.Native American

2.Asian/Pacific Islander

3.Black

4.White

5.Hispanic

Pursuant to Connecticut General Statutes Section 10-221d, the State Board of Education must submit, periodically, a database of applicants for an initial issuance of a certificate, authorization or permit to the State Police Bureau of Investigation for a criminal history record check. Each applicant seeking an initial issuance or renewal of a certificate, authorization or permit must also submit to a records check of the Department of Children and Families’ child abuse and neglect registry established pursuant to Connecticut General Statutes Section

17a-101k. In addition, the State Board of Education is required to submit periodically for criminal history records check the database of all persons who hold any certificate, authorization or permit.

NOTE: If you answer “YES” to any of the above questions, you must attach a signed statement of explanation. If there are multiple incidents within each question, you must list and explain each separately. Submit official copies of court or administrative record(s), including disposition of each case.

Original Signatures Must Be On The Form Submitted

PAGE 1

ED 177

PART II: EDUCATIONAL BACKGROUND

List the names of the colleges or universities attended:

		Dates Attended	Major Field	Degree
Name of Institution	State/Country	From To	of Study	Awarded

PART III: CANDIDATE ATTESTATION

I certify that the information provided by me on this application and any accompanying documents contains no material misrepresentations, falsifications or omissions and that all of the information given by me is true, complete and accurate. I understand that all application and accompanying information may be verified and that any material misrepresentation, falsification or omission may result in the denial or revocation of my certificate(s), permit(s) or authorization(s).

By checking the “I Agree” box, you agree your typed signature is the legal equivalent of your manual signature on this application.

I Agree

SIGNATURE OF CANDIDATE:

DATE:

PART IV:

SCHOOL OR DISTRICT REQUEST FOR FIRST ISSUANCE OF THE DSAP

1.No certified candidate suitable for the position is available to serve in the subject(s) requested. I hereby request issuance of a DSAP for the applicant to serve as:

		Endorsement Required for Position
Specific Subject or Field to be Taught
	Grade Level

(see endorsement code list)

Check box if bilingual endorsement is sought in above subject.

Indicate language of the bilingual endorsement

2.List the steps that have been taken to secure a suitable certified person, including dates and specific locations of newspaper, media, vacancy notices, university postings, Internet job positions, teacher agency listings, etc. Please note that advertisements must be within 6 months.

a. Total number of candidates who applied for this position:

b. Number of candidates who hold appropriate Connecticut certification:

c. Number of candidates interviewed for this position:

d.Reason(s) why certified candidates, if any, were not hired. Include any circumstances and conditions which make this position difficult to fill:

3.Indicate why a DSAP is requested for this particular uncertified applicant.

Information on this application is subject to disclosure pursuant to the Freedom of Information Act.

PAGE 2

ED 177

PART V: ATTESTATION AND SIGNATURE OF EMPLOYING AGENT

The candidate named on this application:

Has been or will be entered into the Connecticut State Department of Education (CSDE) electronic staff file Educator Data System (EDS), with an assignment code appropriate to the endorsement sought under the DSAP.

Will be given special attention in the form of supervision and other assistance, as appropriate.

Signature of Superintendent, Executive Director or Designee
		Date
attesting to accuracy of information
(Original Signature: No Signature Stamps Accepted)
Typed or Printed Name of Person Signing Above
		Title
School or District		Telephone
City	State Zip Code
		E-mail Address – School or District Contact
		Person

Fax

PAGE 3

ED 177

PART VI:

SCHOOL OR DISTRICT REQUEST FOR REISSUANCE OF THE DSAP

1. I hereby request reissuance of a DSAP for the applicant to serve as:

Specific Subject or Field to be Taught Grade Level Endorsement Required for Position

(see endorsement code list)

Check box if bilingual endorsement is sought in above subject.

Indicate language of the bilingual endorsement

PART VII: ATTESTATION AND SIGNATURE OF SCHOOL OR DISTRICT

The candidate named on this application:

Has completed a minimum of nine semester hours of credit in the subject or field requested during the validity period of the previous DSAP.

Has or will be entered into the CSDE Educator Data System (EDS), with an assignment code appropriate to the endorsement sought under the DSAP.

Has successfully served under the previously issued DSAP.

Will be given special attention in the form of supervision and other assistance, as appropriate.

An ED 177 Attachment is being submitted, if enrollment in a program is required for the endorsement.

Signature of Superintendent, Executive Director or Designee		Date
attesting to accuracy of information
(Original Signature: No Signature Stamps Accepted)
Typed or Printed Name of Person Signing Above
			Title
School or District		Telephone
City	State Zip Code
		E-mail Address – School or District Contact
			Person

Fax

PAGE 4

ED 177 – Attachment

REV. 9/20

CONNECTICUT STATE DEPARTMENT OF EDUCATION

Bureau of Educator Standards and Certification

P.O. Box 150471

Hartford, CT 06115-0471

www.ct.gov/sde/cert

EVIDENCE OF ENROLLMENT IN AN APPROVED EDUCATOR PREPARATION PROGRAM

NOTE: This ED 177 Attachment need not be completed if the candidate holds a valid Connecticut teaching certificate and is completing course work toward a cross endorsement (except for endorsements 102, 112, or 113).

PART A: Verification of Employment (this part must be completed by the employing agent)

Candidate’s Last Name	First Name		MI		Social Security Number
Position/Subject or Field
Position/Subject or Field		Grade Level		Endorsement Required for Position

(see endorsement code list)

Check box if bilingual endorsement is sought in above subject.

Indicate language for the bilingual endorsement

The candidate named above is being considered for a position which requires the completion of course work under a Durational Shortage Area Permit (DSAP).

Signature of Superintendent, Executive Director or Designee			Date
(Original Signature: No Signature Stamp Accepted)
Typed or Printed Name of Person Signing Above			Title
School or District			Telephone
City	State	Zip Code	E-mail Address – School or Disrict Contact Person

PAGE 5

ED 177 – Attachment (continued)

Name of Applicant:

PART B: Evidence of Enrollment or Application to an Approved Planned Educator Preparation Program

Evidence of Enrollment for Admission to an Approved Planned Educator Preparation Program

The above-named candidate is currently enrolled in or has applied and been accepted for admission to a approved planned program leading toward the institution’s recommendation for certification in:

Position/Subject or Field

Grade Level

Date of Enrollment or Date of Acceptance into the Program

Total number of semester hours of credit required to complete this certification program:

Number of semester hours of credit the candidate has already completed:

PART C: Attestation and Signature of the Certification Officer or the Academic Director of the Alternate Route to Certification (ARC) Program

Signature of Certification Officer or			Date
Academic Director of the ARC Program
Typed or Printed Name of Person Signing Above
				Title
Educator Preparation Provider (College, University, ARC)			Telephone
City	State	Zip Code
			E-mail Address

Mail Completed Form To:

CONNECTICUT STATE DEPARTMENT OF EDUCATION

Bureau of Educator Standards and Certification

P.O. Box 150471

Hartford, CT 06115-0471

Information on this application is subject to disclosure pursuant to the Freedom of Information Act.

PAGE 6

Common Questions

What is the Connecticut Ed 177 form?

The Connecticut Ed 177 form is an application for the Durational Shortage Area Permit (DSAP). This permit allows schools or districts to fill teaching positions that cannot be filled by candidates who have the appropriate certification. The application must be submitted by the employing school or district and cannot be initiated by the individual seeking the permit.

Who can apply for a DSAP using the Ed 177 form?

Only school or district officials can apply for a DSAP using the Ed 177 form. Candidates themselves cannot initiate the application process. The employing agent must ensure that all parts of the form are completed and that the necessary documentation is submitted to the Bureau of Educator Standards and Certification.

What documents must accompany the Ed 177 form?

When submitting the Ed 177 form, candidates must attach official transcripts that show they have completed at least 12 semester hours of credit in the subject area for which the DSAP is requested. If the candidate has never held certification in Connecticut, a transcript showing the completion of a bachelor’s degree is also required. Additional documents may be needed based on the candidate’s prior teaching experience or current enrollment in a teacher preparation program.

When should the Ed 177 form be submitted?

The Ed 177 form must be submitted prior to the first day of employment for the candidate. If all requirements for issuance have been met, the effective date of the DSAP can be the date the original form is received. Therefore, timely submission is crucial to ensure that the candidate can start their position without delay.

What happens if the candidate has prior teaching experience?

If the candidate has at least 20 school months of successful teaching experience in an approved nonpublic school, they may not need to complete certain sections of the application or provide the “Evidence of Enrollment” form. This applies specifically if the candidate is pursuing coursework under a DSAP for a cross endorsement, except for specific endorsements such as 102, 112, or 113.

Can the Ed 177 form be used for reissuance of a DSAP?

Yes, the Ed 177 form can also be used for the reissuance of a DSAP. In this case, the candidate must complete Parts I, II, and III of the application and provide official transcripts showing the completion of at least nine semester hours of credit during the validity period of the previous DSAP in the subject area for which the new DSAP is requested.

Where should the completed Ed 177 form be sent?

The completed Ed 177 form, along with all supporting documentation, should be submitted to the Bureau of Educator Standards and Certification at the Connecticut State Department of Education. The address is P.O. Box 150471, Hartford, CT 06115-0471. It is advisable to keep a copy of the submitted application for your records.

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Guide to Filling Out Connecticut Ed 177

Filling out the Connecticut Ed 177 form is an important step in applying for a Durational Shortage Area Permit (DSAP). This process involves providing personal information, educational background, and supporting documents. Following the steps carefully will help ensure that the application is completed accurately and submitted correctly.

Begin by obtaining the Connecticut Ed 177 form from the Connecticut State Department of Education website.
In Part I, provide your personal information. Use blue ink and print in uppercase letters. Include your last name, first name, Social Security number, address (no P.O. Box), city, state, ZIP code, gender, birth date, former last name(s), and phone numbers (home/cell and work).
Optionally, indicate your race/ethnicity. Answer the three questions regarding criminal history, dismissal from a position, and any previous credential issues. If you answer "YES" to any question, attach a signed statement of explanation.
In Parts II and III, detail your educational background. Attach official transcripts showing completion of at least 12 semester hours in the subject area for which the DSAP is requested. If you have never held certification in Connecticut, also include an official transcript of your bachelor’s degree.
Once you have completed Parts I, II, and III, submit the form to the appropriate school or district official.
The school or district official will complete Parts IV and V of the application. They must also fill out the “Evidence of Enrollment” form (ED 177 Attachment) – Part A, if applicable. This part should be returned to you for signature by the higher education official if you are enrolling in a teacher preparation program or Alternate Route to Certification program.
If you hold a valid Connecticut certificate and are completing coursework under a DSAP for a cross endorsement, the Attachment is not required.
Finally, ensure that all sections are completed and all necessary documents are attached before submission to the Bureau of Educator Standards and Certification.

Once the form is submitted, the Bureau will review your application. If everything is in order, you will be notified regarding the status of your permit. Be sure to keep a copy of your submitted application for your records.

Dos and Don'ts

When filling out the Connecticut Ed 177 form, there are important guidelines to follow to ensure a smooth application process. Here are six things you should and shouldn't do:

Do complete Parts I, II, and III of the application form accurately.
Do attach official transcripts that show the completion of at least 12 semester hours of credit in the relevant subject area.
Do submit the application before the first day of employment to avoid delays.
Do ensure that all signatures are original on the submitted form.
Don't initiate the application process yourself; it must be submitted by the employing agent.
Don't forget to include any required documentation, such as a signed statement if you answer "YES" to any background questions.