This form must be completed for all instructional personnel including native speakers of English. Non-compliance may result in a $10,000 fine for the Department. Summary of Policy regarding the Act

Appointee Name: ________________________________ Department: __________________________

Complete either Section I or Section II below by checking the appropriate statement and return this form to the Office of the Provost, 607 Warner Hall.

Section I. Certified to Teach Undergraduates

I certify that this appointment is in compliance with the Pennsylvania English Fluency in Higher Education Act, for the following reason:

Native speakers of English

( )The appointee's native language is English and he/she is known to be fluent.

Non-native speakers of English

For graduate assistants and teaching interns:
( )The appointee received an acceptable score (Pass or Restricted I) on the International Teaching Assistant (ITA) Test administered by the Intercultural Communication Center.

For faculty members:
( )The appointee has been interviewed and evaluated by the dean, department head, or their designee and a senior faculty member, and has been determined to be fluent in English. (All interviewers must be native speakers of English.) NOTE: Department head signature is required for faculty.

Signature of department head: ____________________________________ Date: __________

Signature of second interviewer: __________________________________ Date: __________

Section II. Exempt from Certification Requirement

I certify that the appointee is exempt from the provisions of this law because:

( )The appointee is a visiting faculty member
( )The appointee will not teach undergraduate courses
( )The appointee will teach classes in a foreign language

Form submitted by: ________________________________ Date: __________

Title & Department: ________________________________