Impact Study to Inform the Teacher and School Leader Incentive Program

APPENDIX B

Teacher Leader Applicant Background Form

OMB No.: xxxx-xxxx

Expiration Date: xx/xx/xxxx

Impact Evaluation to Inform the Teacher and School Leader Incentive Program

Conducted on behalf of the U.S. Department of Education

Teacher Leader Applicant Background Form

District name:
School name:

A. Teacher’s Background

Applicant’s first and last name:
Applicant’s district ID #
Years of teaching experience:	In the district: | | | Over career: | | |
Gender:
Race/ethnicity:

B. Initial Screening Information

Table B1. Supporting evidence of prior effectiveness over last three years

Applicant’s effectiveness ratings	District scale (prefilled by study team)	2018-19	2017-18	2016-17
a. Teaching location		□ Within district □ Within state □ Outside of district and state	□ Within district □ Within state □ Outside of district and state	□ Within district □ Within state □ Outside of district and state
b. Overall rating	1. Distinguished 2. Accomplished 3. Effective 4. Developing	| |	| |	| |
c. Overall rating based on classroom observations	1. Distinguished 2. Accomplished 3. Effective 4. Developing	| |	| |	| |
d. Value-added (if available): Overall	Scores – Continuous Ratings: 1. at or above +0.5, exceeds expected growth 2. between -0.5 and +0.5, meets expected growth 3. at or below -0.5, does not meet expected growth	Score: | | Rating: | |	Score: | | Rating: | |	Score: | | Rating: | |
e. Value-added (if available): Math	Scores – Continuous Ratings: 1. at or above +0.5, exceeds expected growth 2. between -0.5 and +0.5, meets expected growth 3. at or below -0.5, does not meet expected growth	Score: | | Rating: | |	Score: | | Rating: | |	Score: | | Rating: | |
f. Value-added (if available): ELA	Scores – Continuous Ratings: 1. at or above +0.5, exceeds expected growth 2. between -0.5 and +0.5, meets expected growth 3. at or below -0.5, does not meet expected growth	Score: | | Rating: | |	Score: | | Rating: | |	Score: | | Rating: | |
g. Student achievement growth (e.g. SLOs): Math	Exemplary Proficient Needs Improvement Unsatisfactory	| |	| |	| |
h. Student achievement growth (e.g. SLOs): ELA	Exemplary Proficient Needs Improvement Unsatisfactory	| |	| |	| |
i. Other evidence: (specify)

Table B2. Initial Screening Summary

Item	3-Strong	2-Acceptable	1- Borderline	0-Unacceptable
Explanation of prior effectiveness data	□	□	□	□
Short essay responses	□	□	□	□
Cover letter	□	□	□	□
Resume	□	□	□	□
Overall score on initial screen	□	□	□	□

Teacher moves to advanced screening

1 □ Yes 0 □ No

C. Advanced Screening

Table C1. Behavioral Event Interview

	Level High (5) Low (1)
	5	4	3	2	1
Competency: Achievement	□	□	□	□	□
Competency: Impact & Influence	□	□	□	□	□
Competency: (specify)	□	□	□	□	□

Table C2. Skill Demonstrations

	4-Advanced	3-Proficient	2-Working Towards	1-Needs Improvement
Coaching conversation	□	□	□	□
Instruction (e.g., mini-lesson)	□	□	□	□
Use of data	□	□	□	□
Other demonstration: (specify)	□	□	□	□

D. Overall Application Rating

	3-Strong	2-Acceptable	1- Borderline	0-Unacceptable
Overall application	□	□	□	□
Notes: