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Application for Consideration of an Third Party Collaboration


Personal Support Worker

This form is to be completed by a Third Party Service Provider as application for consideration of the provision of a Personal Support Worker in-classroom student support within schools of the Kawartha Pine Ridge District School Board. This form is to be submitted to the Supplemental Student Services Committee in keeping with Administrative Regulation ES - 3.8.4 and in accordance with PPM 149.

Part A: Third Party Information

Agency provides service in:
 
Validation of agency status
 

Part B: Nature of Request

Request for a Personal Support Worker(s) to be funded by the Third Party Service Provider:
 

Part C: Service Description

Service time lines:
 

Part D: Staff Qualifications and Responsibilities (Complete if external to KPRDSB)

Part E: Supervision Schedule (Complete if external to KPRDSB)

Part F: Accessibility in our Schools

Part G: Statement of Finances

Third Party Service Providers requesting consideration for funding a Personal Support Worker through KPRDSB shall be responsible only for reimbursing the Board for the actual expenses incurred including salary and salary-related costs and related expenditures, including transportation and special services. The amount will be communicated to the Third Party Service Provider prior to the completion of the Collaboration Agreement.

Part H: Evaluation of Service

Part I: Police Records Check

It is understood that
 

Part J: Proof of Insurance

It is understood that:
 

Part K: Proof of Certificate of Clearance

It is understood that:
 

Part L: Application Submission Information

Please print & sign form and submit to address below (right-click on document and select print):

 

I certify that the information provided above is accurate and true to the best of my knowledge.

____________________________                        __________________________

     Signature                                                           Position    


Chair of the Supplemental Student Services Committee
Kawartha Pine Ridge District School Board
1994 Fisher Drive, PO Box 7190
Peterborough, Ontario
K9J 7A1

 
For Information Contact:
Secretary - Attendance and Counselling,
Psychological Services and Speech-Language
Extension 2176
Telephone: (705) 742-9773
Toll Free: 1-877-741-4577
Fax: (705) 760-8665
Website: www.kprschools.ca

Part M: FOR OFFICE USE ONLY

Date received: __________________________________


KPRDSB Supplemental Student Services Committee review date: ___________________________


Application Review: 


◊   Program is consistent with KPRDSB's stated mission, vision, and values.


◊   External Personal Support Worker Service does not duplicate services by KPRDSB staff.


◊   Requests is for funding of a KPRDSB staff.


◊   Supervisory relationships are satisfactory.


◊   Adherence to KPRDSB standards of consent, confidentiality, equity, and human rights.


◊   Measurement/evaluation tools meet Board standards.

 
Application: ◊   Approved           ◊   Declined

Reason for Denial: ______________________________________________________



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