Intern Performance Record

KENTUCKY TEACHER INTERNSHIP PROGRAM INTERN PERFORMANCE RECORD
Teacher Intern __________________________________________________________

SSN __________________________________
School _______________________________________ District __________________________________
Observer Name _________________________________________________________
Cycle 1 Meeting - (classroom observations and second committee meeting shall be held between one (1) and sixty (60) instructional days
following the orientation meeting)
Date of Observation ______________________________________________
Subject Area Observed ____________________________ Type of Classroom ________________________________
Ages/Grades of Number of Students in Number of Students Number of Students Number of Students

Students _________ Class __________ having IEP _______ having GSSP ______ having LEP _______
The signatures below verify that the analytic scores and evidence and holistic score for each Standard have been discussed with the
intern.
Observer's Signature ___________________________________________________________________________
Intern's Signature ______________________________________________________________________________
Cycle 2 Meeting - (classroom observations and third committee meeting shall be held between sixty-one (61) and 110 instructional days
following the orientation meeting)
Date of Observation ____________________________________________

Students _________ Class __________ having IEP ________ having GSSP ______ having LEP ________
intern.
Observer's Signature____________________________________________________________________________
Cycle 3 Meeting - (video or classroom observations and fourth committee meeting shall be held between 110 and 140 instructional
days following the orientation meeting)
Date of Observation ____________________________________________

Students __________ Class __________ having IEP ________ having GSSP ______ having LEP _______
intern.
Observer's Signature ___________________________________________________________________________
Page 1 March 2008

STANDARD 1: DEMONSTRATES APPLIED CONTENT KNOWLEDGE
The teacher demonstrates a current and sufficient academic knowledge of certified content areas to develop student knowledge and performance in
those areas.
Cycle 1 Source(s) of Evidence Cycle 2 Source(s) of Evidence Cycle 3 Source(s) of Evidence
Task A: Lesson Plan Task A: Lesson Plan Task A: Lesson Plan(s) for Observed Lesson(s)
Task B: Classroom Observation Task B: Classroom Observation Task B: Observed Lesson(s) From Unit
Task I: Designing Instructional Strategies and
Activities
Task G: Designing the Instructional Unit
Task H: The Assessment Plan
HOLISTIC SCORING OF STANDARD 1

Standard Demonstrated Standard Partially Demonstrated Standard Not Demonstrated
Cycle 1 3+ 3 3- Cycle 1 2+ 2 2- Cycle 1 1+ 1

ANALYTIC SCORING OF STANDARD 1 INDICATORS

Indicator Indicator Partially Indicator Not
Rating Indicator
Demonstrated Demonstrated Demonstrated
Indicator Rating
D PD ND
1.1 Communicates Accurately and effectively Accurately communicates Inaccurately and ineffectively Cycle 1
concepts, processes communicates concepts, concepts, processes and communicates concepts, D PD ND NA
and knowledge processes and/or knowledge knowledge but omits some processes and knowledge
and uses vocabulary that is important ideas, uses Cycle 2
clear, correct and appropriate vocabulary inappropriate for D PD ND NA
for students students Cycle 3
D PD ND NA
1.2 Connects content Effectively connects content, Connects some content, Fails to connect content, Cycle 1
to life experiences of procedures, and activities procedures, and activities with procedures, and activities D PD ND NA
students with relevant life experiences relevant life experiences of with relevant life experiences
of students students of students Cycle 2
D PD ND NA
Cycle 3
D PD ND NA
1.3 Demonstrates Uses instructional strategies Uses instructional strategies Fails to use instructional Cycle 1
instructional that are clearly appropriate for that are somewhat strategies that are D PD ND NA
strategies that are the content and processes of appropriate for the content appropriate for the content
appropriate for the lesson and make a clear and processes of the lesson and processes of the lesson Cycle 2
content and contribution to student and make some contribution or make no contribution to D PD ND NA
contribute to student learning to student learning student learning
learning Cycle 3
D PD ND NA
1.4 Guides students Provides opportunities and Sometimes provides Fails to provide opportunities Cycle 1
to understand guidance for students to opportunities and guidance for and guidance for students to D PD ND NA
content from various consider lesson content from students to consider lesson consider lesson content from
perspectives different perspectives to content from different different perspectives to Cycle 2
extend their understanding perspectives to extend their extend their understanding D PD ND NA
understanding Cycle 3
D PD ND NA
1.5 Identifies and Identifies misconceptions Identifies misconceptions Fails to identify and address Cycle 1
addresses students’ related to content and related to content and misconceptions related to D PD ND NA
misconceptions of addresses them during both addresses them during either content during planning and Cycle 2
content planning and instruction planning or instruction instruction D PD ND NA
Cycle 3
D PD ND NA
Page 2 March 2008

TPA EVIDENCE TO SUPPORT SCORING OF STANDARD 1
Cycle 1
Cycle 2
Cycle 3
If more space is needed for evidence, additional pages are provided at the end of this document. Remember to
obtain the appropriate signatures on additional pages.
Page 3 March 2008

STANDARD 2: DESIGNS & PLANS INSTRUCTION
The teacher designs/plans instruction that develops student abilities to use communication skills, apply core concepts, become self-sufficient individuals,
become responsible team members, think and solve problems, and integrate knowledge.

Pre-observation conference Pre-observation conference Task G: Designing the Instructional Unit
Contextual information Contextual information Task H: The Assessment Plan
Task I: Designing Instructional Strategies and
Activities



Rating Indicator
Indicator Rating
D PD ND
2.1. Develops States learning objectives States learning objectives Uses objectives that are not Cycle 1
significant objectives that reflect key concepts that reflect key concepts of clearly stated or are trivial D PD ND NA
aligned with standards of the discipline and are the discipline but are not and are not aligned with
aligned with local or state aligned with local or state local or state standards Cycle 2
standards standards or states learning D PD ND NA
objectives that do not reflect Cycle 3
key concepts of the discipline D PD ND NA
2.2 Uses contextual Plans and designs Plans and designs some Fails to plan and design Cycle 1
data to design instruction based on instruction based on instruction based on D PD ND NA
instruction relevant to contextual (i.e., student, contextual (i.e., student, contextual (i.e., student, Cycle 2
students community, and/or community, and/or cultural) community, and/or cultural) D PD ND NA
cultural) and pre- and pre-assessment data and pre-assessment data Cycle 3
assessment data D PD ND NA
2.3 Plans assessments Prepares assessments Prepares some assessments Prepares few assessments Cycle 1
to guide Instruction that measure student that measure student that measure student D PD ND NA
and measure learning performance on each performance on each performance on each Cycle 2
objectives objective and help guide objective and help guide objective and help guide D PD ND NA
teaching teaching teaching. Cycle 3
D PD ND NA
2.4 Plans instructional Aligns instructional Aligns some instructional Aligns few instructional Cycle 1
strategies and activities strategies and activities strategies and activities with strategies and activities with D PD ND NA
that address learning with learning objectives learning objectives for all learning objectives for all Cycle 2
objectives for all for all students students students D PD ND NA
students Cycle 3
D PD ND NA
2.5 Plans instructional Plans instructional Plans instructional strategies Plans instructional strategies Cycle 1
strategies and activities strategies that include that include at least two that do not include levels of D PD ND NA
that facilitate multiple several levels of learning levels of learning with at least learning or do not require Cycle 2
levels of learning that require higher order one requiring higher order higher order thinking D PD ND NA
thinking thinking Cycle 3
D PD ND NA
Page 4 March 2008

Cycle 1
Cycle 2
Cycle 3
If more space is needed for evidence, additional pages are provided at the end of this document. Remember to obtain the
appropriate signatures on additional pages.
Page 5 March 2008

STANDARD 3: CREATES & MAINTAINS LEARNING CLIMATE
The teacher creates a learning climate that supports the development of student abilities to use communication skills, apply core concepts, become self-
sufficient individuals, become responsible team members, think and solve problems, and integrate knowledge.

Post-observation Conference Post-observation Conference
Contextual information Contextual information



Rating Indicator
Indicator Rating
D PD ND
3.1 Communicates high Sets significant and Sets significant and challenging Fails to set significant and Cycle 1
expectations challenging objectives for objectives for students but challenging objectives for D PD ND NA
students and does not communicate students and does not
verbally/nonverbally confidence in students' ability communicate confidence Cycle 2
communicates confidence to achieve these objectives in students D PD ND NA
in students' ability to Cycle 3
achieve these objectives D PD ND NA
3.2 Establishes a Establishes clear Makes efforts to establish Fails to establish clear Cycle 1
positive learning standards of conduct, standards of conduct, and expectations for student D PD ND NA
environment shows awareness of monitor and respond to student conduct, and does not
student behavior, and behavior, but efforts are effectively monitor Cycle 2
responds in ways that are ineffective and/or inappropriate behavior, and does not D PD ND NA
both appropriate and appropriately respond to Cycle 3
respectful of students behavior D PD ND NA
3.3 Values and supports Uses a variety of strategies Sometimes uses a variety of Fails to use a variety of Cycle 1
student diversity and and methods to support strategies and methods to strategies and methods to D PD ND NA
addresses individual student diversity by support student diversity by support student diversity Cycle 2
needs addressing individual addressing individual needs by addressing individual D PD ND NA
needs needs Cycle 3
D PD ND NA
3.4 Fosters mutual Treats all students with Sometimes treats students with Fails to treat students with Cycle 1
respect between teacher respect and concern and respect and concern and respect and concern and D PD ND NA
and students and among monitors student sometimes monitors student monitor student
students interactions to encourage interactions to encourage interactions to encourage Cycle 2
students to treat each other students to treat each other students to treat each D PD ND NA
with respect and concern with respect and concern other with respect and Cycle 3
concern D PD ND NA
3.5 Provides a safe Creates a classroom Creates a classroom Fails to create an Cycle 1
environment for learning environment that is both environment that is sometimes emotionally and D PD ND NA
emotionally and physically emotionally and physically safe physically safe Cycle 2
safe for all students for all students environment for students D PD ND NA
Cycle 3
D PD ND NA
Page 6 March 2008

STANDARD 4: IMPLEMENTS & MANAGES INSTRUCTION
The teacher introduces/implements/manages instruction that develops student abilities to use communication skills, apply core concepts, become self-
sufficient individuals, become responsible team members, think and solve problems, and integrate knowledge.

Post-observation Conference Post-observation Conference
Contextual information Contextual information



Rating Indicator
Indicator Rating
D PD ND
4.1 Uses a variety of Uses a variety of Uses a variety of instructional Fails to use instructional Cycle 1
instructional strategies instructional strategies that strategies that engage students strategies that engage D PD ND NA
that align with learning engage students throughout the lesson on tasks students and are aligned
objectives and actively throughout the lesson on but are not aligned with learning with learning objectives Cycle 2
engage students tasks aligned with learning objectives or tasks are aligned D PD ND NA
objectives with learning objectives but do Cycle 3
not keep students engaged D PD ND NA
4.2 Implements Implements instruction Implements instruction based on Fails to implement Cycle 1
instruction based on based on contextual limited use of contextual instruction based on D PD ND NA
diverse student needs information and information and assessment data contextual information and
and assessment data assessment data assessment data Cycle 2
D PD ND NA
Cycle 3
D PD ND NA
4.3 Uses time effectively Establishes efficient Establishes procedures for Fails to establish
procedures for performing performing non-instructional procedures for performing Cycle 1
non-instructional tasks, tasks, handling materials and non-instructional tasks, D PD ND NA
handling materials and supplies, managing transitions, handling materials and
supplies, managing and organizing and monitoring supplies, managing Cycle 2
transitions, and organizing group work that vary in their transitions, and organizing D PD ND NA
and monitoring group work effectiveness so there is some and monitoring group work
so that there is minimal unnecessary loss of instructional resulting in significant loss Cycle 3
loss of instructional time time of instructional time D PD ND NA
4.4 Uses space and Uses classroom space and Sometimes uses classroom Fails to use classroom Cycle 1
materials effectively materials effectively to space and materials effectively to space and materials D PD ND NA
facilitate student learning facilitate student learning. effectively to facilitate Cycle 2
student learning D PD ND NA
Cycle 3
D PD ND NA
4.5 Implements and Instruction provides Instruction provides some Instruction provides little or Cycle 1
manages instruction in opportunity to promote opportunity to promote higher- no opportunity to promote D PD ND NA
ways that facilitate higher-order thinking order thinking higher-order thinking Cycle 2
higher order thinking D PD ND NA
Cycle 3
D PD ND NA
Page 7 March 2008

OBSERVATION EVIDENCE TO SUPPORT SCORING OF STANDARD 1, 3, 4, 5, AND 6
Cycle 1
Cycle 2
Cycle 3
Page 8 March 2008

OBSERVATION EVIDENCE TO SUPPORT SCORING OF STANDARD 1, 3, 4, 5, AND 6
Cycle 1
Cycle 2
Cycle 3
Page 9 March 2008

STANDARD 5: ASSESSES & COMMUNICATES LEARNING RESULTS
The teacher assesses learning and communicates results to students and others with respect to student abilities to use communication skills, apply core
concepts, become self-sufficient individuals, become responsible team members, think and solve problems, and integrate knowledge.

Task C: Lesson Analysis and Evaluation Task C: Lesson Analysis and Evaluation Task C: Lesson Analysis and Evaluation
Contextual information Contextual information Task G: Designing the Instructional Unit
Task H: The Assessment Plan
Task I: Designing Instructional Strategies and Activities
Task J: Organizing and Analyzing Results


Rating Indicator
Indicator Rating
D PD ND
5.1 Uses pre- Uses a variety of pre- Uses some pre-assessments to Fails to use pre-assessments Cycle 1
assessments assessments to establish establish baseline knowledge to establish baseline D PD ND NA
baseline knowledge and skills and skills for all students knowledge and skills for all Cycle 2
for all students students D PD ND NA
Cycle 3
D PD ND NA
5.2 Uses formative Uses a variety of formative Uses some formative Fails to use formative Cycle 1
assessments assessments to determine each assessments to determine each assessments to determine D PD ND NA
student’s progress and guide student’s progress and guide each student’s progress and Cycle 2
instruction instruction guide instruction D PD ND NA
Cycle 3
D PD ND NA
5.3 Uses summative Uses a variety of summative Uses some summative Fails to use summative Cycle 1
assessments assessments to measure assessments to measure assessments to measure D PD ND NA
student achievement student achievement student achievement Cycle 2
D PD ND NA
Cycle 3
D PD ND NA
5.4 Describes, Describes, analyzes, and Evaluates student performance Fails to describe, analyze, or Cycle 1
analyzes, and evaluates student performance data to determine progress of evaluate student performance D PD ND NA
evaluates student data to determine progress of individuals but does not identify data to determine progress of Cycle 2
performance data individuals and identify differences in progress among individuals or identify D PD ND NA
differences in progress among student groups differences in progress among Cycle 3
student groups student groups D PD ND NA
5.5 Communicates Communicates learning results Sometimes communicates Fails to communicate learning Cycle 1
learning results to to students and parents that learning results to students and results to students and parents D PD ND NA
students and parents provide a clear and timely parents that provide a clear and that provide a clear and timely
understanding of learning timely understanding of learning understanding of learning Cycle 2
progress progress progress D PD ND NA
relative to objectives relative to objectives relative to objectives Cycle 3
D PD ND NA
5.6 Allows Promotes opportunities for Promotes some opportunities for Fails to promote opportunities Cycle 1
opportunity for students to engage in accurate students to engage in accurate for students to engage in D PD ND NA
student self- self-assessment of learning self-assessment of learning accurate self-assessment of Cycle 2
assessment learning D PD ND NA
Cycle 3
D PD ND NA
Page 10 March 2008
Cycle 1
Cycle 2
Cycle 3
Page 11 March 2008

STANDARD 6: DEMONSTRATES THE IMPLEMENTATION OF TECHNOLOGY
The teacher uses technology to support instruction; access and manipulate data; enhance professional growth and productivity; communicate and
collaborate with colleagues, parents, and the community; and conduct research.

Task B: Classroom Observation Task B: Classroom Observation Task B: Observed Lesson(s) from Unit
Post-observation Conference Post-observation Conference Task G: Designing the Instructional Unit
Technology documentation Technology documentation Task H: The Assessment Plan
Task I: Designing Instructional Strategies and Activities
Task J: Organizing and Analyzing the Results



Rating Indicator
Indicator Rating
D PD ND
6.1 Uses available Uses technology to design Sometimes uses Rarely or never uses Cycle 1
technology to design and plan instruction technology to design and technology to design and plan D PD ND NA
and plan instruction plan instruction instruction. Cycle 2
D PD ND NA
Cycle 3
D PD ND NA
6.2 Uses available Uses technology to implement Sometimes uses Rarely or never uses Cycle 1
technology to instruction that technology to implement technology to implement D PD ND NA
implement facilitates student learning instruction that facilitates instruction and facilitate student Cycle 2
instruction that student learning learning D PD ND NA
facilitates student Cycle 3
learning D PD ND NA
6.3 Integrates Integrates student use of Sometimes integrates Rarely or never integrates Cycle 1
student use of technology into instruction to student use of technology student use of technology into D PD ND NA
available technology enhance learning outcomes into instruction to enhance instruction to enhance learning Cycle 2
into instruction and meet diverse student learning outcomes and outcomes and meet diverse D PD ND NA
needs meet diverse student needs student needs Cycle 3
D PD ND NA
6.4 Uses available Uses technology to assess Sometimes uses Rarely or never uses Cycle 1
technology to assess and communicate student technology to assess and technology to assess and D PD ND NA
and communicate learning communicate student communicate student learning Cycle 2
student learning learning D PD ND NA
Cycle 3
D PD ND NA
6.5 Demonstrates Ensures that personal use Sometimes ensures that Fails to ensure that personal Cycle 1
ethical and legal use and student use of technology personal use and student use and student use of D PD ND NA
of technology are ethical and legal use of technology are technology are ethical and Cycle 2
ethical and legal legal D PD ND NA
Cycle 3
D PD ND NA
Page 12 March 2008

Cycle 1
Cycle 2
Cycle 3
Page 13 March 2008

STANDARD 7: REFLECTS ON AND EVALUATES TEACHING AND LEARNING
The teacher reflects on and evaluates specific teaching/learning situations and/or programs.

Task C: Lesson Analysis and Evaluation Task C: Lesson Analysis and Evaluation Task C: Lesson Analysis and Evaluation
Post-observation Conference Post-observation Conference Task J: Organizing and Analyzing the Results



Rating Indicator
Indicator Rating
D PD ND
7.1 Uses data to Reflects on and accurately Reflects on and evaluates Fails to reflect on and evaluate Cycle 1
reflect on and evaluate evaluates student learning student learning without student learning D PD ND NA
student learning using using data
appropriate data Cycle 2
D PD ND NA
Cycle 3
D PD ND NA
7.2 Uses data to Reflects on and accurately Reflects on and evaluates Fails to reflect on and evaluate Cycle 1
reflect on and evaluate evaluates instructional instructional practice without instructional practice D PD ND NA
instructional practice practice using appropriate using data
data Cycle 2
D PD ND NA
Cycle 3
D PD ND NA
7.3 Uses data to Identifies areas for Identifies areas for Fails to identify areas for Cycle 1
reflect on and identify professional growth using professional growth without professional growth D PD ND NA
areas for professional appropriate data using data
growth Cycle 2
D PD ND NA
Cycle 3
D PD ND NA
Page 14 March 2008

Cycle 1
Cycle 2
Cycle 3
Page 15 March 2008

STANDARD 8: COLLABORATES WITH COLLEAGUES/PARENTS/OTHERS
The teacher collaborates with colleagues, parents, and other agencies to design, implement, and support learning programs that develop student
abilities to use communication skills, apply core concepts, become self-sufficient individuals, become responsible team members, think and solve
problems, and integrate knowledge.

Task D: Collaborate to Address Special Task D: Collaborate to Address Special Task D: Collaborate to Address Special
Learning Needs Learning Needs Learning Needs

Cycle 1 Insufficient Evidence Cycle 1 2+ 2 2- Cycle 1 1+ 1


Rating Indicator
Indicator Rating
D PD ND
8.1 Identifies Identifies one or more Identifies one or more students Fails to identify a student Cycle 1
students whose students whose learning whose learning could be whose learning could be D PD ND NA
learning could be could be enhanced by enhanced by collaboration but enhanced by collaboration Cycle 2
enhanced by collaboration and provides does not provide an D PD ND NA
collaboration an appropriate appropriate Cycle 3
rationale rationale D PD ND NA
8.2 Designs a plan to Designs a plan to enhance Designs a plan to enhance Fails to design a plan to Cycle 1
enhance student student learning that student learning that includes enhance student learning D PD ND NA
learning that includes includes all parties in the some parties in the Cycle 2
all parties in the collaborative effort collaborative effort D PD ND NA
collaborative effort Cycle 3
D PD ND NA
8.3 Implements Implements planned Implements planned activities Fails to implement planned Cycle 1
planned activities that activities that enhance that enhance student learning activities D PD ND NA
enhance student student learning and engage and engage some parties Cycle 2
learning and engage all parties D PD ND NA
all parties Cycle 3
D PD ND NA
8.4 Analyzes data to Analyzes student learning Analyzes student learning data Fails to analyze student Cycle 1
evaluate the data to evaluate the to evaluate the outcomes of learning data to evaluate the NA
outcomes of outcomes of collaboration BUT does not outcomes of collaboration Cycle 2
collaborative efforts collaboration and identify identify next steps and does not identify next D PD ND NA
next steps steps Cycle 3
D PD ND NA
Page 16 March 2008

Cycle 1
Cycle 2
Cycle 3
Page 17 March 2008

STANDARDS 9: EVALUATES TEACHING & IMPLEMENTS PROFESSIONAL DEVELOPMENT
The teacher evaluates his/her overall performance with respect to modeling and teaching Kentucky's learning goals, refines the skills and processes
necessary, and implements a professional development plan.

Task E: Assess and Manage Professional Task E: Assess and Manage Professional Task E: Assess and Manage Professional
Growth Growth Growth



Rating Indicator
Indicator Rating
D PD ND
9.1 Self assesses Identifies priority growth Assesses current Fails to assess current Cycle 1
performance relative to areas and strengths by performance performance D PD ND NA
Kentucky's Teacher thoroughly and accurately on all the Kentucky Teacher on all the Kentucky Teacher
Standards assessing current Standards Standards Cycle 2
performance D PD ND NA
on all the Kentucky Teacher Cycle 3
Standards D PD ND NA
9.2 Identifies priorities Identifies priorities for Identifies priorities for Fails to identify priorities for Cycle 1
for professional professional development professional development professional development D PD ND NA
development based on based on data from self- based on limited data from based on data from self-
data from self- assessment, student self-assessment, student assessment, student Cycle 2
assessment, student performance and feedback performance and feedback performance and feedback D PD ND NA
performance and from colleagues from colleagues from colleagues
feedback from Cycle 3
colleagues D PD ND NA
9.3 Designs a Designs a clear, logical Designs a clear, logical Fails to design a clear, Cycle 1
professional growth professional growth plan that professional growth plan that logical professional growth D PD ND NA
plan that addresses addresses all priority areas addresses some priority plan that addresses priority Cycle 2
identified priorities areas areas D PD ND NA
Cycle 3
D PD ND NA
9.4 Shows evidence of Shows clear evidence of Shows some evidence of Fails to show evidence of
professional growth professional growth and professional growth and professional growth and Cycle 1
and reflection on the reflection relative to the reflection relative to the reflection relative to the NA
identified priority areas identified priority areas and identified priority areas and identified priority areas and
and impact on impact on impact on impact on Cycle 2
instructional instructional effectiveness instructional effectiveness instructional effectiveness D PD ND NA
effectiveness and and student learning and student learning and student learning
student learning Cycle 3
D PD ND NA
Page 18 March 2008

Cycle 1
Cycle 2
Cycle 3
Page 19 March 2008

STANDARD 10: PROVIDES LEADERSHIP WITHIN SCHOOL/COMMUNITY/PROFESSION
The teacher provides professional leadership within the school, community, and education profession to improve student learning and well-being.

Task F: Leadership Task F: Leadership Task F: Leadership



Rating Indicator
Indicator Rating
D PD ND
10.1 Identifies Identifies leadership Identifies leadership Fails to identify leadership Cycle 1
leadership opportunities in the school, opportunities in the school, opportunities in the school, D PD ND NA
opportunities that community, or professional community, or professional community, or professional
enhance student organizations and selects one organizations and selects one organizations with potential for Cycle 2
learning and/or with the potential for positive with limited potential for positive impact on learning D PD ND NA
professional impact on learning or the positive impact on learning and/or the professional
environment professional environment and and/or the professional environment
is realistic in terms of environment Cycle 3
knowledge, skill, and time D PD ND NA
required
10.2 Develops a plan Develops a leadership work Develops a leadership work Fails to develop a leadership Cycle 1
for engaging in plan that describes the plan that provides a limited work plan that describes the D PD ND NA
leadership activities purpose, scope, and description of the purpose, purpose, scope, and
participants involved and how scope, and participants participants involved and how Cycle 2
the impact on student learning involved and how the impact the impact on student learning D PD ND NA
and/or the professional on student learning and/or the and/or the professional
environment will be assessed professional environment will be assessed Cycle 3
environment will be assessed D PD ND NA
10.3 Implements a Implements the approved Partially implements the Fails to implement the Cycle 1
plan for engaging in leadership work plan that has approved leadership work approved leadership work plan D PD ND NA
leadership activities a clear timeline of plan that has a clear timeline that has a clear timeline of Cycle 2
events/actions and a clear of events/actions and a clear events/actions and a clear D PD ND NA
description of how impact will description of how impact will description of how impact will Cycle 3
be assessed be assessed be assessed D PD ND NA
10.4 Analyzes data Analyzes student learning Provides limited analysis of Fails to analyze student Cycle 1
to evaluate the and/or other data student learning and/or other learning and/or other data NA
results of planned appropriately to evaluate the data to evaluate the results of appropriately to evaluate the Cycle 2
and executed results of planned and planned and results of planned and D PD ND NA
leadership efforts executed leadership efforts executed leadership efforts executed leadership efforts Cycle 3
D PD ND NA
Page 20 March 2008

Cycle 1
Cycle 2
Cycle 3
appropriate signatures on additional pages
Page 21 March 2008
Education Professional Standards Board
Each intern must receive a copy of each committee members’ completed and
signed Intern Performance Record (IPR) at the conclusion of each committee
meeting.
Important Dates
The Confirmation of Employment (COE) is created and submitted online within

30 days from the date of hire or on or before:
October 15 for full-year or fall semester interns,
February 15 for spring semester interns,
whichever occurs first.
The Record of Teacher Internship Year (RTIY) is created and submitted online
on or before:
May 1 for full year interns,
December 20 for second semester interns,
or no later than two weeks following the final committee meeting, whichever
occurs first.
Unsuccessful Internships
If an internship is unsuccessful, the Committee must submit to the KTIP District

Coordinator, who then submits to the EPSB’s Division of Professional Learning
and Assessment no later than five days after submission of the final report:
the teacher performance assessment (Tasks A-J), including the intern’s
video (if one is available)
a copy of the school calendar
all original Intern Performance Records
any electronic communication sent to intern along with read receipt and
response back from intern (if available)
the electronically signed Record of Teacher Internship Year.
Resource Teacher Time Sheets (RTTs) are created and submitted online.
For directions on:

• Submitting committee reports using the Intern Management System (IMS)
• Obtaining or re-setting IMS passwords
• Creating or adding to Resource Teacher Time Sheets
go to http://www.kyepsb.net/
CYCLE _______ EVIDENCE TO SUPPORT SCORING OF STANDARD(S) _____________________
Remember to obtain the appropriate signatures on each page. Be sure to mark Cycle and Standard in the blanks
provided at the top of this page.
Observer’s Signature ______________________________________________ Date: ________________________

Intern’s Signature _________________________________________________ Date: ________________________
CYCLE _______ EVIDENCE TO SUPPORT SCORING OF STANDARD(s) _____________________








Remember to obtain the appropriate signatures on each page. Be sure to mark Cycle and Standard in the blanks provided
at the top of this page.


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KENTUCKY TEACHER INTERNSHIP PROGRAM INTERN PERFORMANCE RECORD

Teacher Intern __________________________________________________________

Subject Area Observed ____________________________ Type of Classroom ________________________________

Ages/Grades of Number of Students in Number of Students Number of Students Number of Students

Date of Observation ____________________________________________

Subject Area Observed ____________________________ Type of Classroom ________________________________

Ages/Grades of Number of Students in Number of Students Number of Students Number of Students

Subject Area Observed ____________________________ Type of Classroom ________________________________

Ages/Grades of Number of Students in Number of Students Number of Students Number of Students

Page 1 March 2008

HOLISTIC SCORING OF STANDARD 1

Cycle 1 3+ 3 3- Cycle 1 2+ 2 2- Cycle 1 1+ 1

ANALYTIC SCORING OF STANDARD 1 INDICATORS

Page 2 March 2008

Page 3 March 2008

Cycle 1 Source(s) of Evidence Cycle 2 Source(s) of Evidence Cycle 3 Source(s) of Evidence

HOLISTIC SCORING OF STANDARD 2

Cycle 1 3+ 3 3- Cycle 1 2+ 2 2- Cycle 1 1+ 1

ANALYTIC SCORING OF STANDARD 2 INDICATORS

Page 4 March 2008

Page 5 March 2008

Cycle 1 Source(s) of Evidence Cycle 2 Source(s) of Evidence Cycle 3 Source(s) of Evidence

HOLISTIC SCORING OF STANDARD 3

Cycle 1 3+ 3 3- Cycle 1 2+ 2 2- Cycle 1 1+ 1

ANALYTIC SCORING OF STANDARD 3 INDICATORS

Page 6 March 2008

Cycle 1 Source(s) of Evidence Cycle 2 Source(s) of Evidence Cycle 3 Source(s) of Evidence

HOLISTIC SCORING OF STANDARD 4

Cycle 1 3+ 3 3- Cycle 1 2+ 2 2- Cycle 1 1+ 1

ANALYTIC SCORING OF STANDARD 4 INDICATORS

Page 7 March 2008

Page 8 March 2008

Page 9 March 2008

Cycle 1 Source(s) of Evidence Cycle 2 Source(s) of Evidence Cycle 3 Source(s) of Evidence

HOLISTIC SCORING OF STANDARD 5

ANALYTIC SCORING OF STANDARD 5 INDICATORS

Page 11 March 2008

Cycle 1 Source(s) of Evidence Cycle 2 Source(s) of Evidence Cycle 3 Source(s) of Evidence

HOLISTIC SCORING OF STANDARD 6

Cycle 1 3+ 3 3- Cycle 1 2+ 2 2- Cycle 1 1+ 1

ANALYTIC SCORING OF STANDARD 6 INDICATORS

Page 12 March 2008

Page 13 March 2008

Cycle 1 Source(s) of Evidence Cycle 2 Source(s) of Evidence Cycle 3 Source(s) of Evidence

HOLISTIC SCORING OF STANDARD 7

Cycle 1 3+ 3 3- Cycle 1 2+ 2 2- Cycle 1 1+ 1

ANALYTIC SCORING OF STANDARD 7 INDICATORS

Page 14 March 2008

Page 15 March 2008

Cycle 1 Source(s) of Evidence Cycle 2 Source(s) of Evidence Cycle 3 Source(s) of Evidence

HOLISTIC SCORING OF STANDARD 8

Cycle 1 Insufficient Evidence Cycle 1 2+ 2 2- Cycle 1 1+ 1

ANALYTIC SCORING OF STANDARD 8 INDICATORS

Page 16 March 2008

Page 17 March 2008

Cycle 1 Source(s) of Evidence Cycle 2 Source(s) of Evidence Cycle 3 Source(s) of Evidence

HOLISTIC SCORING OF STANDARD 9

Cycle 1 Insufficient Evidence Cycle 1 2+ 2 2- Cycle 1 1+ 1

ANALYTIC SCORING OF STANDARD 9 INDICATORS

Page 18 March 2008

Subject Area Observed Type of Classroom ____

Subject Area Observed Type of Classroom ____

Subject Area Observed Type of Classroom ____

Observer’s Signature ______________________ Date:

Observer’s Signature ______________________ Date:

Observer’s Signature ______________________ Date:

Observer’s Signature ______________________ Date:

Observer’s Signature ______________________ Date:

Observer’s Signature ______________________ Date:

Observer’s Signature ______________________ Date:

Observer’s Signature ______________________ Date:

Observer’s Signature ______________________ Date:

Observer’s Signature ______________________ Date: