Submit to START
START Effective Practices Leadership Initiative (EPLI)
Recommendation Checklist – 2014-15
Complete this Recommendation Checklist electronically and submit to Melissa Kurek at kurekm@gvsu.edu
Your Name:
Job Title:
Phone Number:
*Email:
Name of EPLI Level 1 Trainer Applicant:
RCN Member (name of RCN): Select your RCN
Administrator (describe position):
Position:
Competency Area this application is pursuing approval: (check the one(s) that apply)
Positive Behavioral Interventions and Supports for Students with ASD
Educational Supports and Strategies for Students with ASD
I have known
(name of EPLI Level 1 Trainer Applicant) for how long and in what capacity?
I submit that the applicant has the following qualifications:
 Holds a Michigan Department of Education credential;
 Is employed by a public school system in Michigan;
 Has at least 3 years of experience working with students with ASD;
 Possesses strong content knowledge of ASD and effective supports for students with ASD;
 Has knowledge and skills in teaming and problem solving;
 Has good public speaking skills and willingness to develop these skills;
 Possesses a strong working relationship and credible reputation with colleagues as demonstrated by
recommendations.
For the following items, mark your response in the box provided using the scale below:
1= strongly agree; 2= agree; 3=neutral; 4=disagree; and 5=strongly disagree
1.
The applicant is dependable and reliable: Select rating
2.
The applicant has a high quality of work: Select rating
3.
The applicant has a positive attitude: Select rating
4.
The applicant has solid technology skills: Select rating
5.
The applicant has good presentation skills: Select rating
6.
The applicant is a team player and would be a strong co-presenter: Select rating
7.
The applicant performs work in a professional manner: Select rating
8.
The applicant has credibility with colleagues: Select rating
START Project Feb 2015
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Submit to START
COMPLETE ONLY THE SECTION BELOW ASSOCIATED WITH THE MODULE(S) FOR
WHICH THE APPLICANT IS APPLYING TO BECOME A TRAINER.
If the applicant is applying for both modules, complete both sections.
1= strongly agree; 2= agree; 3= neutral; 4= disagree; and 5= strongly disagree
Positive Behavioral Interventions and Supports Module:
1. Select rating The applicant has received extensive training (e.g. university courses, workshops,
conferences, etc.) in the areas of PBIS (Positive Behavioral Interventions and Supports), school-wide
positive behavioral supports, functional behavioral assessment (FBA) and individual behavior support
plan development.
2. Select rating The applicant has extensive training and experience implementing effective practices for
students with ASD.
3. Select rating The applicant has been involved in completing more than 5 FBAs for students with ASD.
4. Select rating The applicant has been involved in developing and implementing more than 5 individualized
behavioral support plans.
5. Select rating The applicant has extensive experience working with school-based teams to address
behavioral issues for students with ASD.
Educational Supports and Strategies Module Questions:
1. Select rating The applicant advocates that students with ASD should be primarily educated with students
who are not disabled.
2. Select rating The applicant has a solid understanding of Least Restrictive Environment and how it pertains
to students with ASD.
3. Select rating The applicant has received extensive training (e.g. university courses, workshops,
conferences, etc.) in the areas of special educational law, general education curriculum, differentiation,
and grading.
4. Select rating The applicant has considerable experience promoting access to general education for students
with ASD in my current position.
5. Select rating The applicant has developed numerous ways to differentiate output for students with ASD
so they can access the general education curriculum and general education environments.
NARRATIVE: Provide any additional information you feel is relevant to determining this applicant’s
credentials to become a START EPLI Trainer.
I certify that this applicant meets the specifications and qualifications to be a START EPLI Trainer, and all
information in this application is accurate to the best of my knowledge.
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Signature
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Date
START Project Feb 2015
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