School / Division Professional Development Request Form
This form should be completed by a leader within the division or school who can assist with
organization and delivery of professional development activities and building capacity of
implementation of evidence-based practices for students with ASD across classrooms or division.
*Division leaders include: Special Education Directors, School Administrators, Autism Specialists as well
as Program Specialists who work with individuals with ASD. Parents, teachers, related service
personnel and paraprofessionals are urged to contact one of these leaders within their school division
to assist with specific requests.
Requestor’s Name and Title:
School Division (County/City):
School (if applicable):
Requestor’s Telephone Number:
Requestor’s E-mail:
Date of Request:
Intake Questions:
To provide effective professional development, we want to gain a thorough understanding of the
classrooms/school/division needs and to identify a specific and relevant professional development goal. To
assist us in this measure, please answer the questions below. We understand you may have more than one
need in your classrooms/school/division, however; please prioritize your need and submit one request so we
may address it effectively.
1. What is the area of need for this request? Please choose 1 of the following:
___Communication
___ Academics
___ Instructional Delivery
___Social Skills
___Inclusive Practices
___Self-help Skills
___ Interfering Behaviors
___Other
2. What is the intended goal for this request? Based on the area selected above, please choose 13 goals from the list provided below. (Please make sure your goal(s) reflect the 1-2 areas of
need selected above.)
Communication:
 Assessing abilities
 Determining appropriate student goals
 Learning how to identify and implement evidence-based strategies
 Planning and implementing instruction throughout the day and/or across environments
 Setting up, collecting and analyzing data to make program decisions
 Learning about / how to identify an Augmentative and Alternative Communication (AAC) system
Self-help Skills:
 Assessing abilities
 Determining appropriate student goals
 Learning how to identify and implement evidence-based strategies
 Planning and implementing instruction throughout the day and/or across environments
 Setting up, collecting and analyzing data to make program decisions
Social Skills:
 Assessing abilities
 Determining appropriate student goals
 Learning how to identify and implement evidence-based strategies
 Planning and implementing instruction throughout the day and/or across environments
 Setting up, collecting and analyzing data to make program decisions
Inclusive Practices:
 Assessing abilities
 Determining appropriate student goals
 Learning how to identify and implement evidence-based strategies to deliver instruction
 Learning how to identify and implement evidence-based strategies to adapt the curriculum
 Learning how to identify and implement evidence-based strategies to increase social functioning and peer
interaction
 Learning how to implement practices to support a student transition to a less restrictive environment
 Setting up, collecting and analyzing data to make program decisions
Interfering Behaviors:
 Providing a structured and organized classroom environment
 Designing and implementing a instruction tailored to fit the needs of the student
 Increasing knowledge about interfering behavior, assessment and intervention planning
 Implementing a Functional Behavior Assessment
 Developing and implementing a Behavior Intervention Plan
 Identifying and teaching appropriate replacement behaviors
 Identifying and implementing antecedent-based interventions
 Setting up, collecting and analyzing data to make program decisions
 Identifying and implementing reinforcement
Academics:
 Assessing abilities / academic performance
 Determining appropriate student goals
 Learning how to identify and implement evidence-based strategies to deliver instruction in
literacy/reading
 Learning how to identify and implement evidence-based strategies to deliver instruction in mathematics
 Learning how to identify and implement evidence-based strategies in science or history
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Setting up, collecting and analyzing data to make program decisions
Instructional Delivery:
 Providing a structured and organized classroom environment
 Designing and implementing instruction tailored to fit the needs of the student
 Developing and teaching with visual supports
 Identifying and implementing reinforcement
 Implementing systematic instruction (behavioral approach to teaching using the three-term contingency)
Other:
 Increasing parent/family participation
 Increasing knowledge about ASD and characteristics
 Other (please specify):____________________________________________________________
3. What are the expected outcomes from this professional learning activity for your
classrooms/school/division within the VCU-ACE Tiered Professional Development Model?
___Emerging – Changes in awareness and knowledge
Identifying the need for change and learning about possible interventions that may be solutions. Learning what it
takes to implement the innovation effectively. Establishing resources required to implement the innovation with
fidelity to produce effective outcomes for students.
___Developing- Changes in skill and practices
Using intervention practices to support new ways of teaching by teachers and others working in a school
environment. Integrating new interventions into the repertoires of teachers which are supported by building and
division administration. Advancing skill knowledge for teachers to use science-based interventions and produce
effective outcomes for students. Incorporating resources required to implement the innovation with fidelity.
___Sustaining- Systematic application and fidelity of evidence-based practices
Identifying the need for change and learning about possible interventions that may be solutions. Learning what it
takes to implement the innovation effectively. Establishing resources required to implement the innovation with
fidelity to produce effective outcomes for students.
4. What specific Evidence-based practices do you see being an immediate need in your
classrooms/school/division to support the goal you are requesting? Please choose 1-3 from the
list below:
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Assessment
Data Collection / Analysis
Antecedent-based Interventions
Behavior Intervention Planning
Differential Reinforcement
Discrete Trial Training
Functional Behavior Assessment
Functional Communication Training
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Naturalistic Intervention
Peer-mediated Instruction and Intervention
Pivotal Response Training
Prompting
Reinforcement
Self-Management
Social Narratives
Social Skills Groups
Speech Generating Devices or Augmentative and Alternative Communication
Structured Work Systems
Systematic Instruction (behavioral approach to teaching using the three-term contingency)
Task Analysis
Video Modeling
5. What does the school/division currently use to support professional learning and to increase
knowledge and skills related to ASD and evidence-based practices? Check all that apply.
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Nothing at this time
Didactic training provided through live presentations
Online training developed by division personnel
Educators attend conferences / workshops funded by the division
Educators participate in higher education courses funded by the division
Educators participate in ACE online courses, seminars and/or webcasts
Systematic and planned coaching in the classroom
Communities of practice / learning communities
Other (please specify):__________________________________________________________
6. What are you currently doing to build capacity in the area of Autism Spectrum Disorder in your
school/division? Check all that apply.
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Nothing at this time
A school leader(s) participates in the Communities of Learning in Autism (CoLA)
We have a division-wide leadership team
We have a school-wide leadership team
We have a developed plan for coaching in the classrooms
We organize and support school or division-wide communities of practice / learning communities
We provide professional development a minimum of 3 times per year on topics related to ASD
Other (please specify):__________________________________________________________
7. Who would engage in this professional learning activity related to the goal you identified?
Check all that apply.
___ Special Education Teachers ___ General Education Teachers ___ Autism Specialists
___Paraprofessionals
___ Administrators ___Speech/Language Pathologists
__ School Psychologists ___Division Specialists ___ other
8. How many participants from your classrooms/school/division would participate in this
professional learning request?
 1-10
 11-20
 21-30
 31-50
9. What is the status of your school/division?
___Focus school
___Priority school
___School required to develop an improvement plan
___None of the above