Check sources of information used for report:
___ discussions with teacher
___ discussions with other teachers
___ discussions with chairperson or teacher leader
___ discussions with students
___ discussions with parents
___ classroom visits (number: ______)
___ evidence presented by teacher
___ student achievement data
___ district level information
___ other (specify: ___________________________________________________)

Well Functioning (W) Needs Attention (N) Unsatisfactory (U)

Overall rating W N U

Effective instruction, strategies W N U

Classroom order, discipline W N U

Student progress, achievement W N U

Supports school-wide goals, procedures W N U

Maintains health & safety conditions W N U

Follows Davis Course of Study W N U

Follows Utah Core Curriculum W N U

Ethical practice W U

Areas for which teacher may provide additional data to administrator

Professional development & activity W N U

Student relations W N U
Colleague, staff relations W N U

Parent relations W N U

Knowledge of subject matter W N U


Additional comments:
For items circled as
N or U describe
1. specific problem,
2. evidence/indicators,
3. concrete effects on student learning,
4. actions recommended for teacher, and
5. time-frame for remediation, second data gathering, and employment status.


Action Summary:
_____ Proficient, well functioning: Move to Formative Assessment
______ Continue Summative Assessment
______ Move to Remediation (overall judgment and/or required for any U rating)

____________________________________ ______________________________
(administrator's signature, date) (educator's signature, date)