APPLICATION TO PROVIDE PROFESSIONAL DEVELOPMENT SESSIONS

Cleveland Metropolitan School District

Professional Development Services

APPLICATION TO PROVIDE PROFESSIONAL DEVELOPMENT SESSIONS

Please complete all information requested below and submit at least fifteen (15) days prior to session. I understand sessions submitted through this process will be given a session number. You will receive your session number confirmation via email or if you do not have an email we will send it to the fax number provided below.

Indicates a REQUIRED field.

PROVIDER INFORMATION

YES NO

SELECT TO HAVE SESSION INCLUDED IN THE CMSD PROFESSIONAL DEVELOPMENT CATALOG

PD Provider Type:	Internal CMSD External Organization
School Site/Department/Organization:
Principal's/Department Administrator's Name:
Address:
City/State/Zip:
Phone Number:\|
Fax Number:
Provider's Email::

SESSION INFORMATION
This information is required to determine if this session meets the
Ohio Department of Education's definition of High Quality Professional Development.

Session Title:

*Total Number of Sessions: Total Instructional Contact Hours:
(Per Ohio Department of Education mandate Lunch/Breaks: Must NOT be included when calculating total contact hours.)

** In approximately 50 words, describe in clear, concise language the objectives, content, and ways participants may use the information.:|:

FOLLOW-UP ACTIVITIES
This information is required to determine if this session meets the
Ohio Department of Education's definition of High Quality Professional Development.

Describe in clear, concise language the follow-up activities pertaining to this session.

Research Information
This information is required to determine if this session meets the
Ohio Department of Education's definition of High Quality Professional Development.
(Indicate the source of the scientifically based research upon which this
professional development session is based. Key in the information below.)|

Name/Title
of Research

Year published

TOPIC(S)/DESCRIPTION(S)

(Enter the appropriate codes from the following list in the boxes below, choose no more than (3) three).

Code 1:

Code 2:

Code 3:

INTENDED AUDIENCE:
Key in the intended audience from the list below, choose no more than (3) three.

type if other selected

ADDITIONAL SESSION INFORMATION
This information is required to determine if this session meets the
Ohio Department of Education's definition of High Quality Professional Development.
session: series or single?

SESSION ONE

SESSION TWO

SESSION THREE

SESSION FOUR

SESSION FIVE

Date

month		day
year

month		day
year

month		day
year

month		day
year

month		day
year

Time

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Instructional Hours

Paid / Not Paid

Location Name

Location Address

Instructor(s)

Participant Forms Needed

IF THERE ARE MORE THAN 5 DAYS IN THE SESSION PLEASE COMPLETE ANOTHER APPLICATION

COMPENSATION TYPE:

AMOUNT:

CEUS:

STRATEGIC FOCAL POINTS::

(Enter the appropriate code and strategic focal point from the following list in the box below.)

PROFESSIONAL DEVELOPMENT GOALS::
(Enter the appropriate code and professional development goal from the following list in the box below).:

Code:

PROJECTED SESSION OUTCOME:

(Enter the appropriate code from the following list in the box below.)

DOMAIN EMPHASIS:

This information is required to indicate the performance-based indicators detailed in both Praxis and the CMSD evaluation equivalent.

CONTACT INFORMATION:

Name of person who keyed in this information:
School/Organization of person listed above::
Phone Number of person listed above:
Total estimate number of participant forms needed:		FOR PICK UP? OR MAIL?

You may pick up your forms from the CMSD Administration Building,
but you must make arrangements by contacting the Professional Development Office.

Note: We encourage all providers to continue distributing flyers and/or brochures for their sessions to participants. All providers are responsible for securing their own funding for the proposed professional development session(s)/offering(s).

If you have any questions, contact the Office of Professional Development using the information below.

Please submit the completed application by depressing the

SUBMIT button below.

After depressing the submit button you will automatically receive a confirmation page to print and save for you records.

Thank You!

Professional Development Services
1380 East Sixth Street • Room 225 • Cleveland, Ohio 44114

Phone: (216) 574-8197 • Fax: (216) 574-8109