Request for Professional Development Services/Approval
OFFICE USE: Date Received by Coordinator: ________ in PD dept:________
Use this form to request services &/or approval for PD hours
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Assigned to: ____________________
In best practice, districts & coops determine staff PD needs based on a needs assessment including staff evaluation data, student outcomes data, &
upcoming initiatives. The PD activities would be determined & requested in the Spring in advance of the coming school year.
Due to the new ISBE requirements for professional development, please ensure that all bold sections are complete prior to submission. We will be unable to process the
request until this information is received.
If your request is received less than 1 month in advance, we will be unable to provide PD hours or CEU’s. We will acknowledge receipt of your request.
In-services and workshops require immense staff time for development. For that reason, in addition to the actual presentation, some preparation time will be deducted
from your purchased days for each new workshop and in-service request, where applicable.
District Number
School(s) Participating
Administrator/Coordinator
Requesting
Contact Person
(room host)
Contact Person
Phone
Contact Person email
Time to come from
 SI/RTI  IST PBIS
 Ast Tech N/A -PLC
Date(s) of
PD
Activity
Total # of
contact
hours & clock
hours
PD Hours Provider
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 SASED  District
 no PD hr or CEU’s
Total # of
Participants
# staff
getting PD
hrs
# staff
getting
CEUs
# getting
Cert of
Attendance
Title of Activity
Brief Description of Activity - Staff Learning Objectives/Outcomes
Activity aligns to which Learning Forward
Standards (list)
For 2015, PD Dept will complete this box
Time(s)
Purpose 1– aligns to which
Purpose 2 – aligns to which
Rationale - aligns to which New
Rationale – anticipated impact on student learning or
component(s) of ISBE evaluation
professional standards
Illinois Learning Standards
school improvement
Location(s)
Specify age & population of the students
being served by the audience
Start Time
End Time
Special Education Coordinator Signature: ______________________________
Date: ____________
Please submit this proposal to the appropriate SASED Services Coordinator:
Carol Dahlquist – behavior/SEL, SEL MTSS/PBIS, autism
Christine Martin - academics, goal writing/assessment, RTI/MTSS/systems
P: 630-620-9618 Email: cdahlquist@sased.org
P: 630-916-4812 Email: cmartin@sased.org
Africa Anderson – universal design, assistive technology
P: 630-620-9479 Email: aanderson@sased.org