Instructional Program/App Request Form

Instructional Program/App Request Form
Requestor Information
Name*

First NameLast Name
Email*
example@example.com
Your campus/department*
Campus/location level*
Supervisor Email*
Email for your Principal of direct supervisor
Instructional App/Program Information
Name of instructional app/program*
How will program be accessed*
Targeted content area*
What TEKS are supported by this program?*
Briefly describe the purpose of using this app/program*
Will this resource support a school or continuous improvement goal? If so, which goal? *
Is there research to support its use with a particular population? Please specify.*
Grade levels utilizing app/program*

PKKG123456789101112
Program/App contact information*
We may need to contact the vendor to obtain a signature on a data sharing agreement, to discuss purchasing information, or to discuss technical details of activation/installation. If you have talked to a specific representative, please provide the name and email address here.
URL for product information*
Accounts/Data Privacy

Does the resource gather names or other student information while you are using the product (even if students are not accessing the resource)? Please answer “yes” if the resource provides the ability to enter student information whether it is required or optional.
Does the program/app gather names or student information?*
Funding
Is this a free or paid app/program?*
Total cost if paid*
If paid, who is purchasing the app/program
Budget number if paid
License Information
Licenses purchased*
How many licenses are being provided or purchased?
Who will receive a license?*
Describe who will receive a license. (Ex. all 7th grade Texas History students)
Should be Empty:

Instructional Program/App Request Form

Requestor Information

Instructional App/Program Information

Accounts/Data Privacy

Funding

License Information