Workshop Planning Sheet (Part 2)

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. *

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): *

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) *

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 *

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. *

CDA Area for CDA Candidates. All contact hours spent on this area. Should this Workshop/Webinar be submitted to Gateways for Registry-approval? *

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

Professional Skills, Management and Leadership *

Gateways Content Focus (Choose all that apply. STAR NET workshops will usually be PS, unless otherwise noted.) *

Gateways CCDBG Health and Safety topic(s) this training addresses, if applicable (Choose one, if applicable):

Gateways Training Type (Please choose one.)

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

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

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.

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