UAB Regional Inservice Center Professional Learning Request Form-Region 5
District curriculum leaders and administrators may submit this form to request professional learning support based on district needs.
Requester's Name
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First Name
Last Name
Title or Position
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Work Email
*
example@example.com
School District
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Please Select
Bessemer City
Birmingham City
Empower Community School
Fairfield City
i3Academy
Jefferson County
Leeds City
Legacy Prep
Magic City Acceptance Academy
Midfield City
Tarrant City
Trussville City
OTHER
School Name or Department
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Professional Learning Start Date
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Month
-
Day
Year
Date
Professional Learning End Date
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Month
-
Day
Year
Date
Session Title
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Target Audience
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SESSION DESCRIPTION-You may include the purpose, course objectives, and/or participants' expected outcomes.
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How does the proposed professional learning event fit into your overall school or district plan for educator growth or effectiveness?
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Alabama Core Teaching Standards
Pursuant to the mission of improving the academic achievement of all students in the public schools of Alabama, candidates will align their practice with the following standards modified from the Model Core Teaching Standards developed by the Interstate Teacher Assessment and Support Consortium (InTASC). Select all that apply.
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Learner Development
Learning Differences
Learning Environments
Content Knowledge
Application of Content
Assessment
Planning for Instruction
Instructional Strategies
Professional Learning and Ethical Practice
Leadership and Collaboration
Alabama Teacher Growth Program-ATOT Dimensions
How will this professional learning align to the ATOT dimensions? Please check all that apply.
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Culture and Climate: A learning environment that is created and sustained in which each learner is cared for, is safe, has a sense of belonging, and feels secure to share their thoughts.
Learning: Processes established to ensure learners have opportunities to demonstrate an understanding of the content and apply that knowledge and acquisition of skills.
Essentials: Core competenciesdemonstrated by an effectiveteacher, such as presence anddisposition, pedagogicalknowledge, content knowledge,and management of thelearning environment.
Agency: Actions that foster learners’ ability to self-direct and self regulate their learning.
Relationship: Actions that foster healthy, positive connections between the teacher and learners.
What data or strategic indicator is this request aligned to in your school or district? Please explain and provide supporting documentation below.
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What data or strategic indicator is this request aligned to in your school or district? Upload supporting documentation of data/strategic indicator.
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How will this Professional Learning be evaluated for effectiveness? (check all that apply)
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Teacher Survey
Teacher Observation
Student Assessment Data
Student Work Samples
Book Study
Other-Please explain below
How do you plan to sustain support and ensure transfer of learning?
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Instructional Coaching
Follow-up Professional Learning
PLCs
Other-Please explain below
Are you requesting financial assistance from the UAB Regional Inservice Center for this professional learning?
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Yes
No
Would you like the UABRIC to list this professional learning in PowerSchool?
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Yes
No
Date of Submission
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/
Month
/
Day
Year
Date
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Professional Learning Financial Assistance Request
Complete this form if you would like to request financial assistance from the UAB Regional Inservice Center to fund this professional learning.
Total Amount Requested
*
Budget-Explain how funds will be used.
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Upload Itemized Budget-Please note that the budget total must align EXACTLY with the amount requested.
*
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PowerSchool Professional Learning Request
Complete this form if you would like the UAB Regional Inservice Center to list this professional learning event in PowerSchool.
Total Clock Hours to be Earned
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Delivery Time Frame
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Single Day
Multiple Days
Method of Delivery
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In Person
Virtual
Blended
Other
If the professional learning will be in person, would you like the UABRIC to reserve a location/room for you?
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YES, please reserve a location for us.
NO, we have a location. (You must provide location information below).
Location Information
Location Name and Room Number
Street Address
City
State
Postal / Zip Code
Presenter(s) Name
*
Maximum Number of Participants
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Session Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Session End Time
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Hour Minutes
AM
PM
AM/PM Option
Special Notes or Instructions: Provide any special instructions for participants or link to virtual platform i.e. Zoom or Teams, device requirements, materials, etc.
If available, please upload any handouts or resources you would like participants to have.
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If available, please upload a flyer to to be included in the UABRIC Blazer Blast Professional Learning Newsletter and/or Summer Catalog.
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Thank you for your submission. UABRIC staff will contact you with more information.
Nicole Hill, UABRIC Director
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