DESCRIPTION OF A PROFESSIONAL DEVELOPMENT ACTIVITY FOR CEUs

This form or its equivalent is to be used to document each activity for which CEUs are awarded.  Use additional pages if necessary.

__________________________________________        _________________________

NAME OF PROVIDER                                             PROVIDER NO.

TITLE OF ACTIVITY________________________________________________________________

ASSIGNED ACTIVITY NUMBER :

            _____ _____ _____        _____ _____      _____ _____ _____        _____ _____ _____

Activity Start Date : _____ / _____ / _____                 Activity End Date : _____ / _____ / _____

Number of sessions : ________________                   Evaluation completed (date) : ___________

Dates of sessions :     ________________

Total Contact Hours : _____________    

                  (include only time on task in calculation)      

No. CEUs Awarded :  ____________________

                          (Based upon total contact hours)

Date CEU Certificates Issued : _____ / _____ / _____  

Total No. Participants Awarded CEUs : ________

Name of Presenter(s) if applicable : _______________________________________________________________

Appropriate focus : (cite specific reference to CT Framework, CT Common Core of Learning, CT Common Core of Teaching, and CT Guidelines for Teacher Evaluation & Professional Development)

Learning Outcomes : (as a result of participating in this activity, a participant will….)

*

*

*

Effect on Improved Student Learning : (as a result of this activity indicate how student learning may be improved)

*

*

Additional Requirements for Successful Participation / Completion :

*

*

Describe evaluation methodology : _______________________________________________________________

_________________________________

             CEU Coordinator Signature                                                       Date_____________________