Submit to START
START EPLI (Effective Practices Leadership Initiative)
Level 1 Trainer Application – 2014-15
Note: Complete this application electronically and submit to Melissa Kurek kurekm@gvsu.edu
New Applicant
Returning Applicant – must update fields*
REQUIREMENTS TO APPLY TO BE A LEVEL 1 TRAINER:
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Hold a Michigan Department of Education credential;
Be employed by a public school system in Michigan;
Have at least 3 years of experience working with students with ASD;
Possess strong content knowledge of ASD and effective supports for students with ASD;
Have knowledge and skills in teaming and problem solving;
Have good public speaking skills and willingness to develop these skills;
Possess a strong working relationship and credible reputation with colleagues as demonstrated by
recommendations.
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*Name:
*Home/Cell Phone:
*E-mail:
Yes
*Are you currently employed by a school system in MI?
No
*District / School Name:
School Address:
City:
State:
Zip Code:
School Phone:
*RCN (Regional Collaborative Network): Select your RCN name
Professional Certification:
Job Title:
Professional Discipline:
Provider of Speech & Language
School Psychologist
Social Worker
Occupational Therapist
Special Ed Teacher
General Ed Teacher
Teacher Consultant
Years in current position:
Administrator
Other:
Years working with Students with ASD:
Endorsement in Autism
Interdisciplinary Certificate in Autism
Yes
No
Yes
No
Competency Area(s): √ the module(s) in which you intend to become an EPLI trainer:
NOTE: You must attend the module(s) presented by START staff.
Positive Behavioral Interventions and Supports
Educational Strategies and Supports
You must complete at least 2 additional modules in ONE of the training series listed below to be
considered for EPLI. List the modules you attended or plan to attend:
START Intensive Training series at
List modules attended or plan to attend:
OR RCN Mini Intensive Training series at
START Project Feb 2015
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Submit to START
COMPLETE ONLY THE SECTION BELOW ASSOCIATED WITH THE MODULE(S)
FOR WHICH YOU ARE APPLYING TO BECOME A TRAINER.
If you are applying for both modules, complete both sections.
For the following items, indicate your response in the box provided using the scale below:
1 = strongly agree; 2 = agree; 3 = neutral; 4 = disagree; and 5 = strongly disagree
Positive Behavioral Interventions and Supports Module:
1. Indicate your response I have 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 and I can provide documentation if requested.
2. Indicate your response I have extensive training and experience implementing effective practices for
students with ASD and can provide documentation if requested.
3. Indicate your response I have been involved in completing more than 5 FBAs for students with ASD
and can provide examples if needed.
4. Indicate your response I have been involved in developing and implementing more than 5
individualized behavioral support plans and can provide examples if needed.
5. Indicate your response I have extensive experience working with school-based teams to address
behavioral issues for students with ASD and can provide documentation if requested.
Educational Strategies and Supports Module Questions:
1. Indicate your response I strongly advocate that students with ASD should be primarily educated with
students who are not disabled.
2. Indicate your response I have a solid understanding of Least Restrictive Environment and how it
pertains to students with ASD.
3. Indicate your response I have received extensive training (e.g. university courses, workshops,
conferences, etc.) in the areas of special educational law, general education curriculum, differentation,
and grading and can provide documentation if requested.
4. Indicate your response I have considerable experience promoting access to general education for
students with ASD in my current position and can provide documentation if requested.
5. Indicate your response I have developed numerous ways to differentiate output (e.g. class assignments
and projects) for students with ASD so they could access the general education curriculum and general
education environments and can provide examples, if needed.
NARRATIVE: You may expand on any of the statements above or provide additional information you
believe will support your approval to participate in the EPLI Trainer process.
Name of Supervisor approving your application:
I certify that I meet the specifications and qualifications to be a START Trainer, and all information in this
application is accurate to the best of my knowledge.
Signature
Date
START Project Feb 2015
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