
Please provide the following information:
Name of the school _____________________________________________________________
School address ________________________________________________________________
School phone number __________________________________________________________
| K ___ | 3 ___ | 6 ___ | 9 ___ | 12 ____ |
| 1 ___ | 4 ___ | 7 ___ | 10 ___ | Other ___ |
| 2 ___ | 5 ___ | 8 ___ | 11 ___ |
| Elementary education (all subjects combined) | |
| Mathematics | Science |
| Social Studies | Language Arts |
| Second Languages | Fine Arts |
| Physical Education | Health |
| Vocational education | Computers |
| Special education | Other (please specify ____________) |
Regular full-time teacher
Regular part-time teacher
ltinerant (you teach at more than one school)
Long-term substitute
Other (please specify _______________)
| Yes, one | Yes, more than one | No |
| Yes, one | Yes, more than one | No |
| Daily | Weekly | Monthly | Once or twice a year | Never | Not Available |
| Computers in general | |||||
| Word processing packages | |||||
| Spreadsheets | |||||
| Databases | |||||
| Graphical applications | |||||
| Presentation software (e.g., Power Point) | |||||
| Desktop publishing | |||||
| Any Internet activity | |||||
| Search engines for the Internet (e.g., Infoseek, Yahoo) | |||||
| Hypermedia/Multimedia (e.g., Hypercard) | |||||
| Integrated Learning Systems (e.g., Jostens, CCC) | |||||
| Simulation Programs | |||||
| Drill/Practice Programs, Tutorials |
Lecturer _____ %Coach _____ %
Mediator _____ %
Facilitator _____ %
Total _100_ % (should add up to 100 percent)
| ___Yes | ___No |
|
WHAT PROFESSIONAL DEVELOPMENT SHOULD BE INCLUDED?
|

a. Individual research project, in which you examine your own teaching and your students? learning.
- Yes ______ hours in the past year
- No
b. Individual learning, in which you read journals or other professional publications, browse the Internet, etc.
- Yes ______ hours in the past year
- No
c. Other forms of individual professional development related to the use of technology in teaching (specify) ___________________________________
- Yes ______ hours in the past year
- No
| ___Greatly | ___Somewhat | ___Not at all |

