USD 333 Professional Development Request for Points
Each activity submitted needs to be submitted on a separate form.

Today's Date:  (mm/dd/yyyy) 

 ( Please double check the dates - many are being submitted reversed.)

Your Certification Expiration Date:  (mm/dd/yyyy)         

 First Name:            Last Name: 
                    (Please, no middle names or initials.)

Name of Activity (one or two words):          (or name of class if college credit)

Building where you teach:            (Spec-ed staff should use LCNCK regardless of which building they work in.)

Date of "Knowledge" Activity: (mm/dd/yyyy)    (be sure to include the YEAR in your date)  

Time (1/2 hour increments):  (This is the number of hours involved, NOT what time it started & ended.  Do NOT use colons in this box.)  
 (If this is college credit, please put the number of "CREDIT HOURS", not the amount of "seat time" and put the word "CREDITS" after the number so the committee will know what you are submitting.)

Building Goal Addressed by this Activity: 

Check only one of the following areas.  The response box is below the list. (If completing for "Application" or "Impact" and base points were awarded previously, be sure to complete the "Date of Knowledge Activity" above and attach a copy of your approved "Knowledge" form to your printed copy of this form.) (Need HELP? Click here. Use the BACK button to return to this page.)

Knowledge:  What do I know now that I didn't know before?
                Points = Number of Clock Hours (This establishes your base point.)

 Application:  What am I doing now that I wasn't doing before?
               Points = Base Points x 2

Impact:  What changes have occurred in school / district program or among colleagues as a result of my learning?
               Points = Base Points x  3) 

Service to Profession:  How have I served others in the profession?
            Points =  Number of clock hours for this activity

College Credit
             Points = 20 pts / credit hour

Points requested for Salary Advancement (hours beyond contract at first level in all areas or for presentation prep time)
             Points = 1 point per hour

Number of points requested from above area  

One of the following boxes MUST be checked for any of the areas.  Check only one. (Need HELP? Click here. Use the BACK button to return to this page.)

Content Stds.

Professional Ed. Stds.

Service Stds.

College/Univ Credit

 

In the box below, respond to the question for Application or Impact Level only.  Give a printed copy to your PDC representative.
  (Please keep this brief, 240 characters maximum. Do NOT hit "ENTER" while typing in this box.)
 Print this form for your own records BEFORE you click the submit button.  When submitting for Application or Impact levels, a copy of this form and documentation need to be given to your PDC building representative.

                                                                                                                
             Applicant's Signature