Title Page for Fort Hays State University Performance Assessment
FHSU Identification Number:
Date Submitted:
Content Area of your FPA:
Grade Level of the
Classroom/Students in which
the FPA Unit was Completed:
FPA Unit Topic:
My signature verifies that this FPA is my own work. I understand that any
misrepresentation of facts may result in the denial or revocation of my license.
Signature of Candidate Submitting the FPA: _______________________________________
**Reminder: Submit two typed paper copies of the completed Fort Hays State University
Performance Assessment (FPA) AND one electronic copy submitted in Safe Assignment on
the due date posted in the syllabus and Blackboard. Submit this FPA template and all the
attachments/appendices (diagnostic/summative assessment, formative assessment(s), and
graphs/tables) as one document in Safe Assignment. Do not include students’ samples.
**Your FHSU Identification Number, Name, and School Name should not appear
anywhere in your FPA except on this page.
Revised brw January 2010
FPA Criterion 1-Contextual Information/Learning Environment Adaptations
Table 1: Contextual Factors/Adaptation Chart
Contextual Factor
Given Diversity, Implications for Instruction
Gender:
# of Males (M)
# of Females (F)
Achievement:
# In need of Remediation (B)
# Ready for Instruction (R)
# Advanced (A)
Gender: M=Males, F=Females
Achievement: B=Below, R=At/Ready, A=Above
Environmental Factors (district, school, and classroom, all three must be present):
Community (urban, rural, or suburban / culture make-up):
Classroom’s Ethnic Make-up:
Classroom’s Gender Make-up:
School’s Socio-Economic Status (SES) Make-up:
Students with Special Needs/At Risk Students (See Adaptations in FPA Handbook):
Demonstrates an Awareness of Students’ Background Characteristics:
Demonstrates an Understanding of Cognitive and Non-Cognitive Class Features:
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FPA Criterion 2-Learning Goals and Objectives
Table 2: Goal(s) and Knowledge, Skills, and Reasoning Objectives
Goal: To increase or improve (what) for (grade level) students.
Lower Level/ Subject Matter Knowledge: (K)
State Standard
Benchmark
K1
K2
Middle Level/Skills, Applications: (S)
State Standard
Benchmark
S1
S2
Higher Level/Reasoning Ability: (R)
State Standard
Benchmark
R1
R2
Indicator
Objective
Indicator
Objective
Indicator
Objective
Aligned with State/National Standards:
Lower Level/Content Knowledge Objectives:
Middle Level/Skill or Application Objectives:
Higher Level/Reasoning Objectives:
FPA Criterion 3-Instructional Design and Implementation
Table 3: Instructional Planning, Assessments, and Evidence of Achievement
Date
Objective
Activities
Assessment
Adaptations
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%Met
%
tab
Aligned with Goals and Objectives stated in FPA Criterion Two:
Progressively Sequenced:
Provides Evidence that Context Data (see Criterion 1) is Used in Instructional Decisions:
Use of Community Resources that Strengthen Learning:
Multiple Instructional Strategies:
Provide and Adapt Instructional Strategies:
Active Inquiry and Learner Centeredness:
FPA Criterion 4-Demonstration of Integration Skills
Demonstrates the Ability to Integrate Instruction Across or Within Subject Matter Fields:
Reading Instruction Adaptations (3 specific reading strategies):
Use of Technology Connected to the Objectives of the Unit (candidate and students):
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FPA Criterion 5-Analysis of Classroom Learning Environment
Encourages Effective Communication Among Students (within the unit):
Effective Classroom Management (3 strategies: individual, class, school):
Classroom Environmental Factors that Affect Learning (within the unit):
Positive Student Motivation (within the unit):
Environment Supportive of Student Interaction in Learning Activities (within the unit):
FPA Criterion 6-Analysis of Assessment Procedures
Table 4: Assessment Plan Table
Type of
Learning
Assessment
Objective(s)
Diagnostic (Pre)
Formative
Summative (Post)
Format of Assessment
Table 5: Evidence of Assessment and Achievement
Student
Gender
Achievement Diagnostic Formative
M/F
B/R/A
Score
Score
1
2
Gender: M=Males, F=Females
Formula:
Points
Possible
Summative
Score
Pre/Post
Learning
Gain
Achievement: B=Below, R=At/Ready, A=Above
Summative % – Diagnostic % = Actual Gain = Learning
100% – Diagnostic % Potential Gain
Gain
Revised by brw January 10, 2010
Percent
Mastered
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Documents Sources of Student Readiness to Engage in the Unit:
Discusses Format and Content of the Formal Diagnostic Assessment Instrument:
Presents Diagnostic Assessment Data in Table or Chart:
Discusses Format and Content of the Formative Assessment(s):
Presents Formative Assessment Data in a Table or Chart:
Discusses Format and Content of the Summative Assessment Instrument:
Presents Summative Assessment Data in a Table or Chart:
Table 6: Level and Overall Percent of Student Achievement on Each Objective
Student Objective Objective Objective Objective Objective Objective Total
K1
K2
S1
S2
R1
R2
Results
1
2
3
Overall
Results
Includes Percentages of Students Who Achieved Unit Objectives (Overall Results):
Describes the Level of Student Achievement on Each Unit Objective:
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Provides Evidence of Disaggregation of Data for at Least Two Groups:
Graph Gender here
Graph Achievement Levels here
M/F
B/R/A
total learning gains
total learning gains
Diagnostic Assessment is Utilized for Instruction and Evaluation:
Formative Assessment is Utilized for Instruction and Evaluation:
Summative Assessment is Utilized for Evaluation and Planning for Subsequent Instruction:
Multiple Types of Assessment:
Alignment of Assessments to Objectives and Instruction:
Student Evaluation and Performance Criteria (tied to Criterion 2):
FPA Criterion 7-Reflection and Self-Evaluation
Successful Activities (tied to Criterion 2 Knowledge, Skill, & Reasoning objectives):
Implications for Future Teaching of This Unit Including a Focus on Unsuccessful
Objectives (tied to Criterion 2 Knowledge, Skill, & Reasoning objectives):
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Successful Classroom Adaptations and Implications for Future Adaptations
Communication with Students, Parents, and other Professionals while teaching the unit:
Information From Accreditation Process (define QPA, NCA, or School Improvement & your
involvement):
Implications For Professional Development/Continuous Learning: (2 goals)
Goal 1 (insight while teaching unit):
How will you attain this goal? (professionally):
Goal 2 (insight while teaching unit):
How will you attain this goal? (professionally):
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