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Please enable JavaScript in your browser to complete this form.
Dear Presenter, thank you for taking the time to complete this form. The rest of the form will be completed by STAR NET. Please save a copy of this document for your records and email a completed copy of this document to your contact person so they can complete the remaining sections.
Contact Hours: Click here to enter text.
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To Be Completed by Resource Specialist: Continuing Education Information
Early Intervention Hours for EI Providers Please submit this workshop for EI Credit Hour:
*
Yes
No
Post Date
*
To Be Completed by Resource Specialist: Continuing Education Information (50-100 words)?
EI Principles (If submitting for Early Intervention Credit Hours):
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Support families
Active participation
Collaborative relationships
Specific goals
Comprehensive plans
Periodic monitoring
Quality services
To which of the following State Performance Plan indicators does this workshop relate? To which of the following State Performance Plan indicators does this workshop relate? To which of the following Professional Development Outcomes does this workshop relate? (Choose as many as apply) (Aligns with evaluations and Section 1 on the Approved PD Provider Activity Summary – ISBE Form 73-58)
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Increases the knowledge and skills of school and district leaders who guide continuous professional development
Improves learning of students
Organizes adults into learning communities whose goals are aligned with those of the school district
Deepens educator’s content knowledge
Provides educators with research-based instructional strategies to assist students in meeting rigorous academic standard
Prepare educators to appropriately use various types of classroom assessments
Uses learning strategies appropriate to the intended goals
Provides educators with the knowledge and skills to collaborate
Prepares educators to apply research to decision-making
Provides educators with training on inclusive practices in the classroom that examines instructional and behavioral strategies that improve academic and social-emotional growth outcomes for all students, with or without disabilities, in a general education setting.
Which of the following is the intended impact of the professional development activity? (Aligns with Annual Approved Provider Report – ISBE Form 73-59) Please choose one.
Educator and student growth in regards to content knowledge or skills, or both;
Educator and student social emotional growth;
Alignment to district or school improvement plans.
ECPL Category
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ISBE PD Submission Form
https://www.isbe.net/Pages/c-and-i-pd-event-form.aspx
Choose all that apply (The more the merrier – These area search words). Always choose EC.
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ELA
Science/STEM
PE/Health
SEL
Trauma Informed
Career and Technical Ed
Classroom Environment
Assessment
Nutrition
Educator Evals
Counseling
Social Studies
Math
Special Ed
EL
Fine Arts
Technology
Early Childhood
Teaching Methods/strategies or simply instruction
Special Populations
Community Engagement
Self-Care for Teachers
Other
CDA Area for CDA Candidates. All contact hours spent on this area. Should this Workshop/Webinar be submitted to Gateways for Registry-approval?
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Yes
No
To which of the following Gateways Content Area does this workshop relate? All contact hours spent on this area. Gateways Training Topic Areas (Please choose one.)
ECE, School-Age and Youth Development
Professional Skills, Management and Leadership
ECE, School-Age and Youth Development
CAN = Child Abuse & Neglect
CGD = Child Growth and Development
CIT = Curriculum – Infant/Toddler
CP = Curriculum – Preschool
CSA = Curriculum – School-Age
CSM = Curriculum Strategies & Methodologies
DAP = Developmentally Appropriate Practice
ECT = Early Childhood Theories
EA = Early Art
EL = Early Literacy
ES = Early Science
EM = Early Math
EMUS = Early Music
GD = Guidance and Discipline
HS = Health & Safety
INT = Interactions with Children
LE = Learning Environments (Creating or Maintaining)
NUT = Nutrition
OBS = Observation, Evaluation & Documentation
PHY = Physical Fitness
PLAY = Play
RBD = Research in Brain Development
SN = Special Needs/Inclusion
STN = Standards (Program or Learning)
OTH = Other
Professional Skills, Management and Leadership
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ADM = Administration & Supervision
ADV = Advocacy
DIV = Cultural and Individual Diversity
FAM = Family Dynamics & Relationships
GW = Grant Writing
LEAD = Leadership
MOD = Modeling and Mentoring
PROF = Professionalism
PA = Program Assessment (ERS, Accreditation, etc.)
PLAN = Program Planning and Management
STDEV = Staff Development and Training
TECH = Technology
WELL = Wellness
PROFOTH = Other
Gateways Content Focus (Choose all that apply. STAR NET workshops will usually be PS, unless otherwise noted.)
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PR = Prenatal
I = Infants
T = Toddlers
PS = Preschool Children
SA = School-Age Children
Y = Youth
S = Staff
A = Administrative
PA = Parents
OTH = Other
Gateways CCDBG Health and Safety topic(s) this training addresses, if applicable (Choose one, if applicable):
Prevention/Control of Infectious Disease
Prevention of SIDS/Safe Sleep Practices
Administration of Medication
Prevention/Response to Food/Allergic Reactions
Building/Physical Premises Safety
Prevention of SBS/Abusive Head Trauma
Emergency Preparedness and Response Planning
Handling/Storage of Hazardous Materials
Precautions in Transporting Children
First Aid and CPR Certification
Recognizing/Reporting Child Abuse and Neglect
Promotion of Child Growth, Development, Learning
Nutrition/Age-Appropriate Feeding
Access to Physical Activity
Caring for Children with Special Needs
Other Child Development, Health and Safety Topics
Gateways Training Type (Please choose one.)
IP = In Person
LW = Live Webinar
OTW = Online Training Module
H = Hybrid
SPOTM = Self-Paced Online Training Module
MBT = Multimedia-Based Training
Is training single or multiple sessions? (Please choose one.)
Single
Multiple
Workshop Fee: Free unless noted here.
Workshops are held in the English language.
Should this training appear on the Gateways Statewide Online Training Calendar?
Yes
No
To register:
http://roe.stclair.k12.il.us/starnet
Questions about registration
Call
Dinnia
at
618-825-3968
Review for Credential?
Yes
No
Workshop facility located in what County?
*
To be completed by STAR NET: Collaboration Information (If this is in collaboration with the ECC, please use their collaboration form. If the collaboration does not involve the ECC, please use this form.)
Agency/Collaborator Information
Agency/Program Name
Agency/Program Name
*
Agency/Program Name
Agency/Program Name
Contact Person
Contact Person
*
Contact Person
Contact Person
Email Address
Email Address column 1
*
Email Address column 2
Email Address column 3
Phone Number
Phone column 1
*
Phone column 2
Phone column 3
Fax Number
Fax Number column 1
*
Fax Number column 2
*
Fax Number column 3
*
Workshop Details
Secure and Payment of Location (AV requirements, location arrangement/set-up, guaranteed number shared with location)
Agency Responsible
*
Secure and Payment of Location
Cost
*
Secure and Payment of Location
Notes
*
Secure and Payment of Location
Breakfast arrangements
Agency Responsible
*
Breakfast arrangements
Cost
*
Breakfast arrangements
Notes
*
Breakfast arrangements
Lunch arrangements
Agency Responsible
*
Lunch arrangements
Cost
*
Lunch arrangements
Notes
*
Lunch arrangements
Agency Responsible
Agency Responsible
*
Presenter payment
Cost
*
Presenter payment
Notes
*
Presenter payment
Handouts
Agency Responsible
*
Handouts
Cost
*
Handouts
Notes
*
Handouts
Other handouts (Such as regional information)
Agency Responsible
*
Other handouts
Cost
*
Other handouts
Notes
*
Other handouts
Number of participants/agency
Agency Responsible
*
Number of participants/agency
Cost
*
Number of participants/agency
Notes
*
Number of participants/agency
Providing facilitator
Agency Responsible
*
Providing facilitator
Cost
*
Providing facilitator
Notes
*
Providing facilitator
Registration
Agency Responsible
*
Registration
Cost
*
Registration
Notes
*
Registration
Confirmation letters
Agency Responsible
*
Confirmation letters
Cost
*
Confirmation letters
Notes
*
Confirmation letters
Name tags
Agency Responsible
*
Name tags
Cost
*
Name tags
Notes
*
Name tags
Evaluations and CPDUs
Agency Responsible
*
Evaluations and CPDUs
Cost
*
Evaluations and CPDUs
Notes
*
Evaluations and CPDUs
Attendance prizes
Agency Responsible
*
Attendance prizes
Cost
*
Attendance prizes
Notes
*
Attendance prizes
Give-Aways for ea. participant
Agency Responsible
*
Ea. participant
Cost
*
Ea. participant
Notes
*
Ea. participant
Advertise Workshop
Agency Responsible
*
Advertise Workshop
Cost
*
Advertise Workshop
Notes
*
Advertise Workshop
Other tasks/information
Agency Responsible
*
Other
Cost
*
Other
Notes
*
Other
AGENCY COLLABORATION WORKSHEET
Form is to be completed by ECC and shared with collaborating agency upon completion. All fields to be completed.
Workshop/Webinar Information
Title:
*
Date(s):
*
Time(s):
*
Event ID#:
*
Workshop Location:
*
Location Phone Number:
*
Number of participants max:
*
Agency/Collaborator Information
Agency/Program Name:
Agency/Program Name: column 1
*
Agency/Program Name
Agency/Program Name: column 2
Agency/Program Name
Agency/Program Name: column 3
Agency/Program Name
Contact Person:
Contact Person: column 1
*
Contact Person:
Contact Person: column 2
*
Contact Person:
Contact Person: column 3
*
Contact Person:
Email Address:
Email Address: column 1
*
Email Address:
Email Address: column 2
Email Address:
Email Address: column 3
Email Address:
Phone Number:
Phone column 1
*
Phone Number:
Phone column 2
Phone Number:
Phone column 3
Phone Number:
Contact Person:
Fax Number: column 1
*
Fax Number
Fax Number: column 2
Fax Number
Fax Number: column 3
Fax Number
Presenter Information
Presenter:
*
Cell #:
*
Email:
*
Consultant Fee:
*
Preferred Address:
Home
Work
Work
Home
Workshop/Webinar Details
Responsibilities
Presenter Contact
(Includes obtaining the following information: preferred room arrangement/set-up (e.g., rounds; 2 display tables along wall), agenda, required A/V, will presenter require sleeping room the night before, handout original to be copied)
Agency Responsible
*
Presenter Contact
Comments/Notes
Presenter Contact
Agency who will be paying presenter fee
Location
(Includes securing the following: A/V requirements with location or the person supplying, room arrangement/set-up requested, food order placed with location or outside caterer, guaranteed number shared with location)
Agency Responsible
*
location
Comments/Notes
Location
Secure Virtual Room
(for webinars)
Agency Responsible
Secure Virtual Room
Comments/Notes
Secure Virtual Room
Facilitator
(provide lunch for presenter)
Agency Responsible
Facilitator
Comments/Notes
Facilitator
CPDUs/Evaluations
Agency Responsible
CPDUs/Evaluations
Comments/Notes
CPDUs/Evaluations
Handouts
(include all collaborators on the handout folders including the logo for each agency)
Agency Responsible
*
Handouts
Comments/Notes
Handouts
Process Registrations
Agency Responsible
Process Registrations
Comments/Notes
Process Registrations
Confirmation Letters
Agency Responsible
Confirmation Letters
Comments/Notes
Confirmation Letters
Provide Required Paperwork to workshop
(sign-in sheet, CPDU forms, evaluation forms, printed name tags)
Agency Responsible
Required Paperwork to workshop
Comments/Notes
Required Paperwork to workshop
Other Tasks
Agency Responsible
Other Tasks
Comments/Notes
Other Tasks
Workshop Expenses
Payment
Presenter Contract
Agency Responsible
Presenter Contract
Comments/Notes
Presenter Contract
Presenter Travel
Agency Responsible
Presenter Travel
Comments/Notes
Presenter Travel
Location Invoice
Agency Responsible
Location Invoice
Comments/Notes
Location Invoice
Miscellaneous Expenses
Agency Responsible
Miscellaneous Expenses
Comments/Notes
Miscellaneous Expenses
Presenter Travel Sharing cost
*
Yes
No
If sharing cost, note specific amount here
Agency Responsible
sharing cost
Comments/Notes
sharing cost
Location Invoice Sharing cost
*
Yes
No
Location Invoice
If sharing cost, note specific amount here
Agency Responsible
Location Invoice sharing cost
Comments/Notes
Location Invoice sharing cost
Miscellaneous Expenses Sharing cost
*
Yes
No
Miscellaneous Expenses
If sharing cost, note specific amount here
Agency Responsible
Location Invoice sharing cost
Comments/Notes
Miscellaneous Expenses sharing cost
Additional Notes
STAR NET Staff should complete this form only if the workshop is a WBR.
Is STAR NET taking registrations in Database?
Yes
No
(If taking registration in database participants’ name will appear on certificates, Registration forms will need to be distributed and submitted to star net.)
Is STAR NET Providing Sign in Sheet?
Yes
No
(If sign in sheet is provided, participants names will not appear on certificate and will not be entered into database)
Is STAR NET providing certificates?
Yes
No
(If certificates are provided, training will automatically be submitted for SLP credit and add to list to send for IDFPR credit.)
s STAR NET providing Evaluations?
Yes
No
If providing certificates is there a collaborator that needs to be listed on the certificate?      
Number of participants:
Will Breakfast or lunch be provided?
Yes
No
 
if you want to take door prizes and/or a give-a-way for each person in attendance, please indicate what you would like the support staff to gather for you:
Handouts should be to Dinnia 3 weeks prior to the workshop, which is:
Do you want your handouts in folders?
Yes
No
 
Please indicate what other materials you want and if they should be in the folders or not. If nothing is checked in a row, then that item is not needed.
Materials
Workshop/Webinar At-A-Glance
Data Base Form
Library (Borrower’s Due Date and Library Assistance Forms)
Educational Rights and Responsibilities/Illinois Student Records Keeper
Illinois Early Learning and Development Standards
Little Prints
Regional Brochures
Family Brochures
Workshop/Webinar At-A-Glance
In Folder
Stacked Separately
Data Base Form
In Folder
Stacked Separately
Library (Borrower’s Due Date and Library Assistance Forms)
In Folder
Stacked Separately
Illinois Early Learning and Development Standards
In Folder
Stacked Separately
Educational Rights and Responsibilities/Illinois Student Records Keeper
In Folder
Stacked Separately
Little Prints
In Folder
Stacked Separately
Regional Brochures
In Folder
Stacked Separately
Family Brochures
In Folder
Stacked Separately
Other Brochures/ Flyers/ Workshop Registration Forms/Materials (Please List)
Other Brochures/ Flyers/ Workshop Registration Forms/Materials
In Folder
Stacked Separately
Message
Submit