Moodle Course Request Form 20090714

Moodle System Role Modification Form For Instructor and Course Creator

Los Angeles Unified School District ITD – Educational Technology

Identification (to be completed by user)

Requested Date

Name (First)

(MI)

Position

(Last) Employee No.

LAUSD email

@ lausd.net

School/Office

Phone No. [direct line] (_____) ______-_________ Location Code _______________ Local District

Local District/Central Office Program Name (if applicable) Submission/Agreement (to be agreed to and signed by user) By logging in to the Moodle Learning Platform, I understand that I will have access to confidential class information and agree that: I will not take any action that will jeopardize the security of this information. I will not discuss with non-authorized persons any information regarding users/participants. I will not allow any of this information to be viewed by non-authorized persons. I understand that the use of LAUSD computer equipment, software, and information will be restricted to Districtapproved work only. I will follow all requirements in the LAUSD Acceptable Use Policy (Bulletin 999) and the Information Privacy Policy (Bulletin 1077) found at http://www.lausd.net. I will follow all additional security instructions provided by the District relevant to this system. Agreed/Signed

Date

Moodle Access Requested - School Year 2009 – 2010 Please note: For multiple learning environments, please attach spreadsheet with all information listed below. Semester:  Fall  Spring Calendar:  Single Track  Concept 6  90/30 Track  A  B  C  D Audience:  K-12/Student Use  Adult Use (PD) Type of Shell:  Secondary Template - __________________  AP Online - __________________________  Elementary Template - _________________  Class.com - __________________________  Blank Shell - _________________________  UCCP - ___________________________ Principal’s Name ______________________________Signature ______________________________Date_________ Program Administrator’s Name (if applicable) _____________________________________________Signature_______________________________Date__________

ITD Use Only ( ) REVIEWED

ITD Administrator:______________________/__________________ Date ____/____/____

ITD AUTHORIZATION: ( ) APPROVED

Print Name

Signature

( ) NOT APPROVED

______________________________________________________________________ Date ____/____/____ (Dr. Themistocles Sparangis, Chief Technology Director or Joseph H. Oliver, III, Director-Instructional Technology)

School Mail to: ITD – Educational Technology Group Beaudry Building., 10th Floor Attention: Rudy Rizo, Specialist

OR

Fax to (213) 241 – 6938 Please keep a copy

Rev. 7/14/09