Baltimore City Public School System
Department of Professional Development
Performance-Based Evaluation
Principal Input Form
For IEP Instructional Associate Positions and Clinical Service Providers
(Speech/Language Pathologists, School Psychologists, School Social Workers
Assistive Technology Team Members, Audiologists, Occupational Therapists, Physical Therapists)
Clinical Service Provider/IEP Instructional Associate ________________________________________________________
Employee ID #
Position __________________________________________________
School Name:
School # ______________________________
Principal _______________________________________________________ Date ______________________________
The Principal Input Form is submitted to the appropriate coordinator of the Clinical Service Provider/IEP Instructional Associate at
least twice during the school year. It provides information to be considered in the development of the Performance Review Report
(due January 31st) and the final Evaluation Report (due one week before the last work day in June). This form should be forwarded by
the principal to the appropriate coordinator no later than December 15 th and April 15th of each school year so that the coordinator can
consider the information as evaluation forms are developed. Staff members must be notified of year-end unsatisfactory performance
evaluations on or before May 1st.
The Principal Input Form must be used at other times during the school year:
 to communicate concerns/problems that the principal believes the coordinator/director needs to address.
 to indicate steps taken by the principal to address concerns.
If the staff member provides services in more than one school, each principal should complete the Principal Input Form and forward it
to the appropriate coordinator/director.
Domain 1 – Planning and Preparation

Planning procedures reflect knowledge of procedures related to the position.
Maintains current intervention therapy plans
Submits schedule to administrator
Informs administrator of schedule changes
Yes
Yes
Yes
No
No
No
N/A
N/A
N/A
Comments:______________________________________________________________________________
Domain 2 – The Learning Environment

Organizes and manages responsibilities specific to the position.
Maintains documentation of student attendance & performance
Provides assigned assessments within required timelines
Provides assigned IEP services within required timelines
Completes and submits IEP report cards
Completes and submits TPB documentation
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
N/A
N/A
N/A
N/A
N/A
Comments:______________________________________________________________________________
Domain 3 – Instruction/Instructional Support
 Develops and implements activities and procedures that support the position.
Responds appropriately to the needs of the individual school
(in-service workshops for staff, parent education, etc.
Yes
No
N/A
Resolves conflicts in a professional manner
Oral and written communications are effective
Consults with school staff, families, community agencies when
appropriate
Yes
Yes
No
No
N/A
N/A
Yes
No
N/A
Comments:______________________________________________________________________________
Domain 4 – Professional Responsibilities

Demonstrates responsibilities related to school improvement, school regulations and personal growth.
Responds professionally to special and crisis situations
Participates on School Support Team or other school related
projects/teams
Participates on Child Study Team
Completes with attendance policies and procedures
No. of days absent ________
No. of days late __________
Yes
No
N/A
Yes
Yes
No
No
N/A
N/A
Action Taken ______________________________________
Action Taken ______________________________________
Comments:______________________________________________________________________________
Other Issues/Concerns
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________
Clinical Service Provider/
IEP Instructional Associate Signature ____________________________________
Date _______________________
Principal’s Signature _________________________________________________
Date _______________________
Received by Coordinator _____________________________________________
Date _______________________
Copy – Clinical Service Provider/IEP Instructional Associate
Distribution:
Copy – Principal
Copy - Coordinator