Early Intervention Ongoing Professional Development Plan Format
(Required for all Except Service Coordinators and Parent Liaisons)
I agree to participate in a system of ongoing professional development that includes, at a
minimum, a once a month face-to face meeting with either an individual specialist-level
credentialed provider of the same discipline, or a group, at least one of whom is a specialistleveled credentialed provider of the same discipline, in order to facilitate best practices
through case review. These meetings will be used for professional development through
discussion of client/family: concerns, needs, strengths, resources, priorities, outcomes,
strategies, and service plans (without providing client identifying information) in order to
support best practices.
At least annually, I will document, using the form provided, my participation in a system
of ongoing professional development, for each face-to-face meeting, providing the date and
location of the meeting and the name, credential number, and signature of a credentialed
provider of the same discipline that participated with me in the meeting. I will make
documentation of ongoing professional development meetings available to the Department
upon request. With subsequent credential renewal applications, I will submit to the
credentialing office completed ongoing professional development documentation forms for
the period of my credential, up to the date upon which the renewal application is submitted.
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Early Intervention Credential Number
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Signature
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Date
Must be submitted to Provider Connections with Earl y Intervention Credential Application
Revised 2/04
Ongoing Professional Development Documentation Form
(Required for all Except Service Coordinators and Parent Liaisons)
This form is required to document Ongoing Professional Development. Substitute forms will not be accepted.
Duplicate this form as needed. A copy of this form must be forwarded to Provider Connections with credential
renewal materials documenting ongoing professional development activities for each twelve (12) month
credentialing period.
Provider Name ________________________________________Year _______ (indicate 1, 2, or 3)
Credential # __________________________________________
Date of Meeting
Location
Signature of Credentialed Peer
and Peer’s Credential #
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Must be completed annually and submitted to Provider Connections with credential renewal application
Revised 2/04