Instructional Resource Request
Before beginning this application, please visit the Digital Instructional Resources page on the LCS website:

Once this form is completed, it will be forwarded to Dr. Heather Morin (privacy/support/Clever integration), Rhonda Browning (student information), and Dr. Veronica Brown and/or Julie Klein (teaching/learning and Instructional Framework) for approval.

Please answer each question fully, and please respond to all questions.
Sign in to Google to save your progress. Learn more
Email *
Name of individual making this request *
School *
Title of Program *
Where has this program been successfully implemented? *
Web address for the program/company: *
Name of a contact for the company with email address: *
Standards addressed by this instructional program:   *
Describe how this program will be used for instruction (including target student population, time for use, and coordination with current instruction practices): *
Cost for the program (indicate if site license, by user, or by installed computer) and continuing maintenance/renewal costs: *
Funding source for this instructional program implementation and for subsequent years? *
System requirements.  If web-based, include URL whitelist and/or ports required by the program. *
Is the program vendor a signatory to the Student Privacy Pledge?  *
Provide a link to the program vendor’s Privacy Policy: *
Provide a link to the program vendor’s Terms of Service: *
List any any personally identifiable information (PII) used or stored by the program.  PII “includes direct identifiers, such as a student’s name or identification number, indirect identifiers, such as a student’s date of birth, or other information which can be used to distinguish or trace an individual’s identity either directly or indirectly through linkages with other information” (Privacy Technical Assistance Center, US Department of Education): *
What types of information will be stored or collected by the program? *
Management.  Describe what administration the program will require, including creation/deletion/transfer of users and creation of reports and name the person who will be responsible for this administration. *
What student information will be transmitted, uploaded or keyed into the program? *
Training.  Describe what training will be required, who will provide the training, when training will take place, and cost for training.   *
Once you hit submit on this form, it will be directed to Heather Morin and Lindsey Martin to verify student privacy requirements; Rhonda Browning to verify compatibility with student information systems and Clever; Veronica Brown and/or Julie Klein to verify that alignment with curriculum needs and the instructional framework.
Approval by Julie Klein or Veronica Brown
Approval by Heather Morin or Lindsey Martin
Approval by Rhonda Browning
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Lowndes County Schools. Report Abuse