Professional Educator License
Renewal Form
RENEW ONLINE at
:
USIMS.schools.utah.gov
Do not submit this form to USBE
unless you are notified of
monitoring.
All Professional License renewals require
prior
review and approval of 100 hours completed within
the last five years prior to date of license expiration. Professional License renewals are subject to monitoring
by the Utah State Board of Education (USBE). As such, you are required to keep this original signed renewal
form and supporting documentation for 24 months as evidence to support your online renewal transaction.
The rules and steps for Utah Educator License Renewal can be found at
Renew a Utah Educator License.
License Holder’s Name: ______________________________________________ CACTUS ID#: __________________
Email: _____________________________________________________________________________________________________
License Expiration Date: _____________________________ Phone Number: ______________________________
Have you ever had a credential revoked or suspended that has not been “reinstated” by the
Utah Professional Practices Advisory Commission or by another standards Board?
☐ Yes ☐ No
What is your educator status?
☐ Active Educator: An educator with a
current assignment
in Utah public, charter, or
accredited private school
for all
the previous five (5) years of the renewal submission
☐ Inactive Educator: An educator with
NO assignment
in Utah public, charter, or accredited
private school
for any
of the previous five (5) years of the renewal submission
☐ Returning Educator: An educator
without an assignment
in Utah public, charter, or
accredited private school
for any one
of the previous five (5) years of the renewal submission
NOTE: Inactive and Returning Educators may complete 100 hours in any category for Professional
Educator License Renewal and are not subject to category maximums.
ACTIVE EDUCATOR DURING COVID-19 PANDEMIC
In recognition and acknowledgement of the hard work and abilities educators have adapted to
teach in-person, online, or in a hybrid setting during the COVID-19 pandemic, the Utah State
Board of Education has decided to award 20 renewal hours for each active year in 2019-20,
2020-21 and 2021-22. The Board is thankful and humbled by your hard work and dedication in
putting Utah children above yourself and succeeding in keeping students learning and safe.
I was an active educator in during the following school years:
☐ 2019-2020 School Year (20 hours)
☐ 2020-2021 School Year (20 hours)
☐ 2021-2022 School Year (20 hours) Enter Total COVID-19 Hours:
Utah State Board of Education – Professional License Renewal Form ADA – 11/2022 Page 1
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ITEMIZATION OF LICENSE RENEWAL HOURS EARNED FOR THIS RENEWAL PERIOD
ALL Educators are required by Board rule R277-487-9 to complete the USBE Utah Student Data
Privacy Educator Course.
Date Completed:
Hour:
(max 1 hour)
PROFESSIONAL LEARNING:
Hours for professional learning activities sponsored or approved by a
professional education entity such as university coursework, USBE professional learning events,
curriculum development, school improvement, mentoring/training of new teachers, training/supports
designed for new teachers or teachers identified as ineffective on the teacher’s annual evaluation,
instructional coaching, conferences, workshops, institutes, trainings, symposiums, staff development
programs, or ten hours per year for a teacher evaluation deeming the educator highly effective.
Trainings that are required as a condition of employment count in this category, including: Annual Code
of Conduct Training (R277 322 3), Annual Assessment Ethics Training (R277 404 5), and Youth Suicide
Prevention Training (U.S.C. 53G-9 704). Educators should focus professional learning on their license
content area.
DATE COMPLETED
ACTIVITY DESCRIPTION
ACTIVITY TYPE
HOURS
Total Professional Learning Renewal Hours:
(max 90 hours for an active educator)
Utah State Board of Education – Professional License Renewal Form ADA – 11/2022 Page 2
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EDUCATOR COLLABORATION OPPORTUNITIES:
Hours for opportunities in which educators engage in
data analysis in collaboration with colleagues to inform instructional adjustments and to address
student need, including professional learning communities and team collaboration time.
DATE COMPLETED
ACTIVITY DESCRIPTION
ACTIVITY TYPE
HOURS
Total Collaboration Renewal Hours:
(max 30 hours for an active educator)
PROFESSIONAL SERVICE:
Hours for activities related to service in a local, state, or national government
or professional education association leadership role, including the Utah Legislature, Utah Education
Association, National Education Association, Utah State Board of Education, and local Boards of
Education.
DATE COMPLETED
ACTIVITY DESCRIPTION
ACTIVITY TYPE
HOURS
Total Professional Service Renewal Hours:
(max 50 hours for an active educator)
ALTERNATE LEARNING OPPORTUNITIES:
Hours for activities that enhance or improve the education
related skills and knowledge of an educator serving in a school, but not in a role as the primary
educator, including working as a paraprofessional, substitute teaching in a public school, volunteering
in a public school, traveling with an education purpose or component, presenting at a professional
conference (including the time to design/prepare the presentation), educational research, and serving
as a department chair in a public school.
DATE COMPLETED
ACTIVITY DESCRIPTION
ACTIVITY TYPE
HOURS
Total Alternate Learning Renewal Hours:
(max 50 hours for an active educator)
Attach supplementary pages if you need additional space to document activities.
Utah State Board of Education – Professional License Renewal Form ADA – 11/2022 Page 3
Utah
State
Educator
Bo
a
rd
of
Licensing
Education
TOTAL RENEWAL HOURS
Renewal Hours Type
Total Renewal Hours
COVID-19 Hours (see page 1)
Utah Student Data Privacy Course (see page 2)
Professional Learning (see page 2)
Educator Collaboration Opportunities (see page 3)
Professional Service (see page 3)
Alternate Learning Opportunities (see page 3)
Total Renewal Hours:
(100 hours required for all educators)
VERIFICATION SIGNATURES
License Holder Verification:
I verify these statements and total renewal hours are true and I understand this information may be
used or provided to potential employers and to the Utah State Board of Education for appropriate
licensure purposes. I understand that my Utah renewal may be rescinded, and my license is subject to
disciplinary action if any information on this renewal form is false.
License Holder Signature: ______________________________________________ Date: ______________________
License Holder’s Printed Name: ______________________________________ CACTUS ID#: ________________
Current Licensed Administrator or Utah Charter Director Verification:
I verify that I am a licensed education administrator or Utah charter director and have knowledge of
the Utah Educator License Renewal Rules (R277-302). I have reviewed all renewal activities and ensure
that all renewal hours listed are in compliance with those rules.
Administrator Signature: _______________________________________________ Date: _____________________
Administrator Printed Name: ________________________________________ CACTUS ID#: ________________
Administrator Email: ___________________________________ Phone Number: ___________________________
For Non-Utah Administrators:
Educator License Number: _______________________________________ Issuing State: ___________________
Do not submit this form to USBE unless you are notified of monitoring.
Utah State Board of Education – Professional License Renewal Form ADA – 11/2022 Page 4