Name:       	Submission Date:       	
Job Title:       	
Work Assignment / Location:       	
Home Address:       	
City:       	State:       	Zip:       	
Educator ID:       	IPDP Effective Date:       	
Number of CEUs requested:         (Note maximum CEUs for each type of project)	

Form should be completed after the PD activity	
Directions: Complete sections I, II, III and IV.

I.	How did this professional development activity align to your IPDP goals? How is it part of your overall professional development plan?

     

II.	Overall, what was the most valuable thing you learned from this professional development activity?

     	

III.	How will this professional development activity increase your educator effectiveness and results for students?

     	

IV. Attach required documentation which provides evidence of the completion of the professional development activity for which you received pre-approval. This would include a copy of your original proposal and the following documentation.

Activity	Documentation Required 	Max CEUs per license cycle*	
Peer Coaching 	Activity Log	6 CEUs	
Shadowing, Externships	Activity Log & written reflection	6 CEUs	
Grant Writing or Grant Reviewer
(Note: CEUs not dependent on awarding of grant)	Activity Log & copy of grant	6 CEUs	
Professional Committee (Note: this is intended to reflect work that is conducted outside of the normal work day and work responsibilities)	Activity Log or Contact Hour Certificate/Contact Hour Form & copy of meeting agendas s	3 CEUs	
Curriculum Unit	Activity Log, written summary of project & copy of final product	6 CEUs	
Educational Project	Activity Log, written summary of project & copy of final product	3 CEUs	
Educational Travel	Activity Log, written summary of trip & copy of itinerary	1 CEU	
Peer Observation	Activity Log, written summary of pre and post conference & observation 	1 CEU	
Professional Presentation at workshop or conference	Activity Log, written reflection on presentation; copy of presentation slides	6 CEUs	
Professional Reading	Activity Log & written summary/reflection on readings	1 CEU	
Publication of Original Work	Activity Log & copy of publication	6 to 18 CEUs for book
3 to 6 CEUs for article	
Research, Action Research or Inquiry	Activity Log & Written report of research, findings, & applications	6 CEUs	
School, Community Partnership Initiatives	Activity Log & description of project impact	6 CEUs	
Reflective Portfolio	Activity Log & copy of portfolio	3 CEUs	
Reading Study Group	Activity Log & written summary/reflection on readings	3 CEUs	

DO NOT MARK BELOW THIS LINE. FOR LPDC USE ONLY.
	Approved as written				Revise/Resubmit

Approval Signature_________________________________ Date________________________