Name:       	Submission Date:       	
Job Title:       	
Work Assignment / Location:       	
Home Address:       	
City:       	State:       	Zip:       	
Educator ID:       	IPDP Effective Date:       	
Date(s) of Proposed Professional Development:       	
Type of Proposed Professional Development Activity	
	Activity	Max CEUs per license cycle*	
	Peer Coaching 	6 CEUs	
	Shadowing, Externships	6 CEUs	
	Grant Writing or Grant Reviewer	6 CEUs	
	Professional Committee	3 CEUs	
	Curriculum Unit	6 CEUs	
	Educational Project	3 CEUs	
	Educational Travel	1 CEU	
	Peer Observation	1 CEU	
	Professional Presentation at workshop or conference	6 CEUs	
	Professional Reading	1 CEU	
	Publication of Original Work (Book)	6 to 18 CEUs 	
	Publication of Original Work (Article)	3 to 6 CEUs	
	Research, Action Research or Inquiry	6 CEUs	
	School, Community Partnership Initiatives	6 CEUs	
	Reflective Portfolio	3 CEUs	
	Reading Study Group	3 CEUs	
Description of proposed professional development activity:	

     
	
Connection of proposed professional development to IPDP goals:	

     
	
How will this activity help you grow as a professional educator?	

     	

I understand that CEU/contact hour credit will not be given for this project until I have submitted the Evaluation of Pre-Approved Professional Development Form along with other project specific documentation for review by the LPDC. (See LPDC Handbook for further information)

DO NOT MARK BELOW THIS LINE - FOR LPDC USE ONLY.

Approval Signature_________________________________________ Date________________