1. F3
Revised 9/1/2009
TEACHER EVALUATION/SELF ASSESSMENT FORM
Teacher: Pers. # Position (Grade/Subject):
School: Date:
Evaluator: Evaluator Title:
The evaluator is to indicate the appropriate rating for each domain by placing a circle around the number. Use the
information below to determine the ranking.
Ratin Summary
g
1 Not Demonstrated: Teacher does not demonstrate competence on or adequate growth toward achieving
standards of performance
2 Needs Improvement: Teacher demonstrates limited growth toward achieving standard(s), and does not
demonstrate competence on standard(s) of performance
3 Proficient: Teacher demonstrates basic competence on standard(s) of performance
4 Accomplished: Teacher exceeds basic competence on standard(s) of performance most of the time
5 Expert: Teacher consistently and significantly exceeds basic competence on standards of performance.
Consider the examples below each domain when ranking the teacher. Please give one ranking for the overall
domain. You must provide comments for each domain.
DOMAIN I: PLANNING (Please Circle Rating) 20%
1 2 3 4 5
Not Demonstrated Proficient Expert
Comments:
• Specifies learner outcomes in clear, concise objectives.
• Includes activity/activities that develop objectives.
• Identifies and plans for individual differences.
• Written lesson plans reflect observed classroom instructions.
• Identifies and makes arrangements for materials, other than standard classroom materials, as needed for
the lesson.
• States method(s) of evaluation to measure learner outcomes.
• Develops an Individual Education Plan (IEP), ITP, and/or IFSP (for Special Education teachers only.)
• Develops and maintains a safe and orderly environment supportive of learning.
• Classroom procedures and rules are posted.
• Submits written lesson plans on time according to district guidelines and maintains classroom copy of daily
lesson plans to reflect instructional changes.
• Develops routine activities for students who complete work in advance.
• Plans and provides appropriate homework assignments.
• Makes alternate lesson plans for effective instruction by substitute.
• Prepares and submits accurate reports on time.
• Utilizes technology for information management.
• Plans and prepares assignments for paraprofessionals, volunteers, and/or student teachers, if applicable.
• Plans lessons using student data to drive instruction
• Plans lessons that include higher order thinking skills and higher levels of Bloom’s taxonomy

2. DOMAIN II: MANAGEMENT 15%
1 2 3 4 5
Not Demonstrated Proficient Expert
Comments:
• Organizes and uses space, materials, and/or equipment appropriately to facilitate learning.
• Promotes a positive learning climate using school’s Positive Behavior Support system
• Manages routines and transitions in a timely manner.
• Manages and/or adjusts allotted time for activities planned.
• Establishes expectations for learner behavior.
• Uses monitoring techniques to facilitate learning.
• Consistently enforces school and classroom rules and procedures.
• Listens, observes, and questions students to determine if they are on task.
• Dismisses students in a systematic and orderly fashion.
DOMAIN III:INSTRUCTION 20%
1 2 3 4 5
Not Demonstrated Proficient Expert
Comments:
• Manages Student behaviors to maximize time on task.
• Plans and uses adequate and appropriate instructional methods, including anticipatory set, objective and its purpose,
input, modeling, checking for understanding, monitoring, adjusting, guided practice, and lesson closure.
• Uses technique(s) which develop(s) lesson objective(s).
• Sequences lesson to promote learning.
• Uses appropriate teaching material(s) to achieve lesson objectives.
• Uses research based practices effectively:
• Presents content at a developmentally appropriate level.
• Presents accurate subject matter.
• Relates relevant examples, unexpected situations, or current events to the content.
• Answers questions correctly and/or directs students to additional sources (i.e., references, labs, learning centers, etc.)
• Accommodates individual differences.
• Differentiates and scaffolds instruction for different learners.
• Demonstrates ability to communicate effectively with students.
• Stimulates and encourages higher order thinking at the appropriate developmental levels.
• Encourages student participation.
• Uses a balanced assessment program including locally-developed assessments.
• Produces evidence of student academic growth under his/her instruction.
• Monitors ongoing performance of students.
• Provides timely and specific feedback to students regarding their progress.
• Integrates technology into instruction.
• Uses effective and appropriate questioning techniques to achieve lesson objectives.
• Uses grammatically correct language and models legible handwriting.
• Incorporates motivational strategies into classroom activities.
• Teaches oral and written communication skills.
• Exhibits enthusiasm for subject taught.
• Displays good models of current student work.
• Integrates concepts from other disciplines.
• Posts daily assignments and, when appropriate, timelines for long range projects.
• Holds students accountable for acceptable completion and self-appraisal of assigned work.
• Instructs students in safety procedures included in the district’s Crisis Management and Emergency Response Plan.
• Implements district curriculum with fidelity.
• Utilizes student achievement data to inform instruction.
F3-Summative Evaluation (Teacher) Page 2 of 5

3. DOMAIN IV. PROFESSIONAL DEVELOPMENT 10%
1 2 3 4 5
Not Demonstrated Proficient Expert
Comments:
• Develops professional growth plan related to job responsibilities and school priorities.
• Implements growth plan and job related responsibilities.
• Takes ownership over own professional development in an effort to improve teaching practices.
• Maintains appropriate credentials/certification.
DOMAIN V. SCHOOL IMPROVEMENT 10%
1 2 3 4 5
Not Demonstrated Proficient Expert
Comments:
• Attends, constructively participates in, and follows up on district approved staff development activities.
• Attends and constructively participates in faculty, team, grade-level, WFSG, and or Cluster Team meetings.
• Demonstrates positive support of school, community, and administrative expectations, including school
improvement plan.
• Provides clear and timely information to parents/caregivers and colleagues regarding classroom
expectations, student progress, and ways they can assist learning.
• Encourages parents/caregivers to become active partners in their children’s education and to become
involved in school and classroom.
• Seeks community involvement in instructional program.
DOMAIN VI. EVALUATION 10%
1 2 3 4 5
Not Demonstrated Proficient Expert
Comments:
• Develops uses and correctly interprets evaluation instruments and procedures appropriate to the lesson
objectives.
• Prepares and maintains necessary and required records to document student progress.
• Communicates evaluation procedures to administration, students and parents.
• Uses data driven decisions to enhance teaching and learning
F3-Summative Evaluation (Teacher) Page 3 of 5

4. DOMAIN VII. INTERPERSONAL RELATIONSHIPS 5%
1 2 3 4 5
Not Demonstrated Proficient Expert
Comments:
• Implements and maintains a psychologically safe environment supportive of learning.
• Treats students and colleagues with respect in all settings.
• Provides opportunities for students to demonstrate leadership and responsibility.
• Implements cooperative activities as a regular practice.
• Accepts and uses constructive feedback.
DOMAIN VIII. PROFESSIONAL ATTITUDE AND CONDUCT 10%
1 2 3 4 5
Not Demonstrated Proficient Expert
Comments:
• Practices professional ethics in the community, school, and classroom.
• Reports to all duty stations on time (e.g., classroom, halls, yard, grounds, gym, field experiences)
and properly supervises students.
• Adheres to district guidelines relative to attendance.
• Reports regularly to school on time.
• Adheres to School Board policy and regulations.
• Uses proper administrative procedures for making requests and resolving conflicts.
• Cooperates with administration in the performance of additional duties.
• Displays confident classroom posture and maintains self-control.
• Dresses in a professional manner appropriate for the teaching assignment.
• Participates in professional growth activities which present current educational research and
practice.
F3-Summative Evaluation (Teacher) Page 4 of 5

5. TEACHER EVALUATION/SELF ASSESSMENT FORM
Scoring
Summative Score is the weighted average of all 8 domains. To find the weighted score for each domain,
multiply the percent value by the domain score. The summative score is the total of the weighted scores for
each domain.
Domain Percent Value x Domain Score = Weighted Score
Domain I: Planning 20% x = 0.00
Domain II: Management 15% x = 0.00
Domain III: Instruction 20% x = 0.00
Domain IV: Professional Development 10% x = 0.00
Domain V: School Improvement 10% x = 0.00
Domain VI: Evaluation 10% x = 0.00
Domain VII: Interpersonal Relationships 5% x = 0.00
Dom ain VIII: Professional Attitude and Conduct 10% x = 0.00
Summative Score
Total of Weighed Scores 0.00
Type of Evaluation: Self____ Administrator_____
Score Rating Action to be Taken
1.0-2.0 Not Demonstrated Recommend for termination
2.1-2.9 Needs Improvement Continue to provide support and encourage growth
3.0-3.9 Proficient Continue to provide support and encourage growth
4.0-4.4 Accomplished Provide opportunities to support other teachers
4.5-5.0 Expert Provide opportunities for advancement
After the evaluation of this employee, I hereby recommend that the RSD:
_______Retain Employee _________Release Employee*
(Documentation Attached)
____________________________________________________________________________________
Evaluator Signature Date
____________________________________________________________________________________
Evaluatee Signature Date
My signature indicates that I have received a copy of this evaluation. It does not indicate that I agree with
the evaluation. I understand that if I disagree with the results of this evaluation, I must appeal, in
writing, to Human Resources by May 7, 2010.
*Principals must provide documentation of IAP and follow up in order to recommend “Release Employee”
F3-Summative Evaluation (Teacher) Page 5 of 5