Public Organization Other Than an LEA Applicant

Michigan Educator EvaluationTool

Application

Cover Page

(Form A)

☐LEA applicant

☐Public Organization Other Than an LEA applicant

☐Private Organization Other Than an LEA applicant

Application Submission Date
Applicant Name
Authorized Contact Name and Title
Address
Phone
Fax
E-mail
Tax I.D. Number
Name of Proposed Evaluation Tool
Proposed Evaluation Tool Author(s)
Statement Detailing Rationale for Request

Michigan Educator EvaluationTool

Application

Research Base and Author Qualifications

(Form B)

Please check the appropriate box: / ☐This proposal is for an administrator evaluation tool.
☐This proposal is for a teacher evaluation tool.
Please describe in detail the author’squalifications and attach CV as appendix.
Please describe in detail the research base for the proposed tool.
☐Narrative attached as an appendix rather than included in the text box to the right

Michigan Educator EvaluationTool

Application

Teacher or Administrator Practice Rubric Narrative

(Form C)

Please provide a detailed description of the teacher or administrator practice rubric.

☐Narrative attached as an appendix rather than included in the text box below

Michigan Educator EvaluationTool

Application

Evidence of Reliability

(Form D)

Please provide a detailed description of the reliability study conducted and the conclusions supported by evidence.

☐Narrative attached as an appendix rather than included in the text box below

Michigan Educator EvaluationTool

Application

Validity Study

(Form E)

Please provide a detailed description of the validity study conducted and the conclusions supported by evidence. Additionally, attach as an appendix, a crosswalk from the proposed tool to:

InTASC standards - if submitting a teacher evaluation tool
PSEL standards (formerly ISLLC) - if submitting an administrator evaluation tool

☐Narrative attached as an appendix rather than included in the text box below

Michigan Educator EvaluationTool

Application

Efficacy Study

(Form F)

Please provide a detailed description of the efficacy study conducted and the conclusions supported by evidence.

☐Narrative attached as an appendix rather than included in the text box below

Michigan Educator EvaluationTool

Application

Observation and Evaluation Protocol Detail

(Form G)

Please provide a detailed description of the proposed tool’s observation and evaluation protocol and the research supporting those practices.

☐Narrative attached as an appendix rather than included in the text box below

Michigan Educator EvaluationTool

Application

Professional Development Plan Detail

(Form H)

Please provide a detailed description of the professional development plan supporting initial implementation and ongoing implementation inclusive of all relevant stakeholders.

☐Narrative attached as an appendix rather than included in the text box below

Michigan Educator EvaluationTool

Application

Assurances and Signatures

(Form I)

Michigan School District (LEA) Submitting an Application

By signing this document below the applicant assures all information provided within and accompanying this application packet is accurate and representative of the most current available data/research. Additionally, the authorized representative assures they have been given permission to represent the applicant entity in this application process.

Entity Name
Authorized Representative Name
Authorized Representative Signature
Date

Public or Private Organization Other Than a Michigan LEA

☐Evidence that the evaluation tool has been approved or adopted for use by at least two state education agencies.

☐Evidence that not less than ten districts in this state will consider adopting the evaluation tool if it is added to the list.

Please attach the relevant documentation supporting the identified requirements in pdf format and including the description and file name in form J.

Entity Name
Authorized Representative Name
Authorized Representative Signature
Date

Michigan Educator EvaluationTool

Cultural Competency Detail

(Form J)

*Not required, but requested

Applicant is asked to provide a statement detailing how cultural competency is addressed in the proposed evaluation tool.

☐Narrative attached as an appendix rather than included in the text box below

Michigan Educator EvaluationTool

Implementation Cost Model

(Form K)

*Not required, but requested

Description of Educator Evaluation Tool Implementation Cost Model

☐Narrative attached as an appendix rather than included in the text box below

Relevant Educator Evaluation Tool Expenses

Initial Evaluation Tool Expense
(Please include expenses related to adopting the tool itself and all ancillary resources) / Observation and Feedback Software Licensing Expense
(Please include annual licensing fee for purchase of all available software packages) / Annual Training Expenses
(Please include detailed expenses for initial administrative trainings, initial teacher and other stakeholder trainings as well as ongoing professional development to maintain calibration or to improve/deepen understanding and implementation practices and train-the-trainer initial and ongoing expenses)

Michigan Educator EvaluationTool

Application

Table of Contents for Appendices/Attachments

(Form L)

Please provide a table of contents detailing the appendices/attachments to this application packet to ensure all intended documentation is received by MDE.

Attachment Description / Attachment file name