Fillable Form 1.: Southern Illinois University Carbondale Professional Development (Southern Illinois University-Carbondale)

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Form 1.: Southern Illinois University Carbondale Professional Development (Southern Illinois University-Carbondale)

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Southern Illinois University Carbondale
Professional Development (PD) & Continuing Education Unit (CEU)
Application
1.
Name of activity: __________________________________________________
Date of activity: ___________________________________________________
Location of activity: ________________________________________________
Sponsoring unit(s) for activity: ________________________________________
Contact Name: ____________________________________________________
Address: _________________________________________________________
Phone: ___________________________________________________________
Email: ___________________________________________________________
Person validating participants: _________________________________________
2. Describe the activity.
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3. Explain the intended impact on student learning or well-being. List specific learning
outcomes.
________________________________________________________________________
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4. Method of Delivery: (Please check all that apply and, if any “other” indicate what.)
Lecture/
Discussion On-line chat and discussion
Web pages with course content Web forum (bulletin/web board)
E-mail Other computer software
Dedicated newsgroup Streaming media
Toll-free telephone line Document/application sharing
Real time audio/video Other:
5. If self-paced, time limit for completion: _____________ Weeks _____________Months
6. For Professional Development hours ONLY:
Write a statement showing the relationship between the content of the PD activity, specific
relevant standard(s), and at least one of the following criteria established for PD activities:
Engages participants over a sustained period of time allowing for analysis, discovery, and
application as they relate to student learning, social or emotional achievement, or well-being: or
Aligns to the licensee’s performance (evaluation); or
Includes outcomes that relate to student growth or district improvement; or
Aligns to State-approved standards; or
Are college courses.
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Identify any of the following criteria that apply to this PD activity:
Increases the knowledge and skills of school and district leaders who guide continuous professional
development; or
Improves the learning of students; or
Deepens educator’s content knowledge; or
Uses learning strategies appropriate to the intended goals; or
Organizes adults into learning communities whose goals are aligned with those of the school and
district; or
Provides educators with research-based instructional strategies to assist students in meeting rigorous
academic standards; or
Prepares educators to appropriately use various types of classroom assessments; or
Provides educators with the knowledge and skills to collaborate; or
Prepared educators to apply research to decision-making.
Identify the professional development standards to which the PD activity aligns:
Learning Communities- committed to continuous improvement, collective responsibility, and goal
alignment.
Leadership- skillful leaders who develop capacity, advocate, and create support systems for
professional learning.
Resources- requires prioritizing, monitoring, and coordinating resources for educator learning.
Data- uses a variety of sources and types of student, educator, and system data to plan, assess, and
evaluate professional learning.
Learning Designs- integrates theories, research, and models of human learning to achieve its
intended outcomes.
Implementation- applies research on change and sustains support for implementation of
professional learning for long-term change.
Outcomes- aligns its outcomes with educator performance and student curriculum standards.
7. Criteria for Determining Satisfactory Completion in Awarding CEUs:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
*Please attach supporting materials (i.e. conference program, outline, etc.)
For Of
fice Use Only:
Al
l requirements have been met and approval is hereby recommended:
_______________
__________________________ ____________________
Conference Coordinator
Date
_______________
__________________________ ____________________
Sponsor’s Representative (if applicable) Date
App
roval granted for _______ Professional Development units or _______Continuing
Education units.
_________________________________________ ____________________
Assistant Director, Conference and Scheduling Services
Date
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Form 1.: Southern Illinois University Carbondale Professional Development (Southern Illinois University-Carbondale)

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Completed 12 October 2020

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