GaDOE Use: __Lesson Plan __Evidence _CLIP reviewed ____________ Request Revision and DATE IVA Approval Date: __________ Initials: _____

Directions: Submit completed form and applicable attachments to the Title IV, Part A program specialist One activity, school, date per form Field Trip Approval and subsequent budget approval must occur prior to activity date LEA Title IV, Part A Coordinator will be notified of Approval or Requested Revisions requirements via email Approved at GaDOE, signed/scanned copy will be emailed to district contact LEA must UPLOAD approved Field Trip Expenditure Form and associated documentation into the Consolidated Application portal on INFORMATION tab of Title IV, Part A program and budget activity accordingly.
Title IV, Part A of the ESEA, the Student Support and Academic Enrichment (SSAE) program is intended provide all students with access to a well-rounded education, improve school conditions for student learning, and improve the use of technology in order to improve the academic achievement and digital literacy of all students.

This form must be signed by the Title IV, Part A Coordinator before being submitted to GaDOE.

LEA	Click or tap here to enter text.
Title IV, Part A Coordinator	(Responsible to upload all Title IV, Part A budget, required pre/post activity information into Con App; mark Affirmations) Name/Title/Phone Number/email Click or tap here to enter text.
Date of THIS Submission	Click or tap to enter a date.
School (Considered to be Point of Origination)	Click or tap here to enter text.
School Contact	(Person who is responsible for conducting activity, provide evidence-based documentation, measuring effectiveness) Name/Title/Phone Number/email Click or tap here to enter text.
Grade Level(s)	Click or tap here to enter text.
Content Area(s)	Click or tap here to enter text.
FY20 CLIP OR FY20 S-CLIP (When applicable, CNA, SWP/Strategic Plan required to be uploaded into Con App) Information	Overarching Need DIP GOAL Identify number/provide text	Click or tap here to enter text.
Action Step Identify number/provide text	Click or tap here to enter text.
Field Trip Activity	Name of Venue	Click or tap here to enter text.
Location of Venue	Click or tap here to enter text.
Distance (miles) (from Point of Origination)	Click or tap here to enter text.
**Eligible for Out-of-State	(LEA County Boundary ON GA state line and Venue is a daytrip within 60 miles of Point of Origination) Check One YES☐ NO☐
Date of Field Trip Activity	Click or tap to enter a date.
Evidence-Based Documentation	Submit as an attachment to this form
Lesson Plan(s)	Submit as an attachment to this form
Intended Outcome(s)	Click or tap here to enter text.
Method of Measuring Effectiveness To be submitted to GaDOE vis Title IV, Part A Consolidated Application portal	Results of effectiveness as it pertains to the Overarching Need and Intended Outcome(s) to be submitted to GaDOE not more than 60 days upon completion of field trip activity Select a formatting option: ☐ Feedback/Survey Analysis ☐ Performance Data Analysis ☐ Rating Scales Analysis ☐ Other Click or tap here to enter text.
Participants	Students	#Click or tap here to enter text.
LEA Employees	#Click or tap here to enter text.
Chaperones/Non-employees (counted for seating on transportation)	#Click or tap here to enter text.
Other	#Click or tap here to enter text.
TOTAL	#Click or tap here to enter text.
Estimated Costs	Utilizing Title IV, A funds	Admission Fees/Tickets for students/teacher	$Click or tap here to enter text.
Transportation (Explain type: ex-school bus, charter)	$Click or tap here to enter text.
Other (if applicable explain)	$Click or tap here to enter text.
TOTAL	$Click or tap here to enter text.
Other Federal Funds utilized?	Check One YES☐ NO☐
Other non-federal sources utilized?	Check One YES☐ NO☐
Affirmations (Affirmations to be completed by the Title IV, Part A LEA Coordinator)	I affirm that federal funds will not be utilized to purchase food, clothing, identification materials (ex: lanyards/name tags) lodging and/or gratuities.	Check One YES☐ NO☐
I affirm that this field trip activity occurs solely in the State of Georgia.**	Check One NA☐ YES☐ NO☐
**I affirm that this field trip meets the criteria for OUT-OF-STATE travel as described in the Title IV, Part A Handbook.	Check One NA☐ YES☐ NO☐
I affirm that this activity is not associated with overnight travel.	Check One YES☐ NO☐
I affirm that the attached lesson plan(s) for this field trip includes identified GSE, instructional strategies and pre-/post-trip instructional activities.	Check One YES☐ NO☐
I affirm that the results measuring activity effectiveness will be submitted to GaDOE (upload into Con App) not later than 60 days upon completion of the activity.	Check One YES☐ NO☐

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Printed Name of Title IV, Part A Coordinator Signature Date Signed Affirmations